MINDANAO PSYCHOLOGY CONVENTION

OFF-CAMPUS ACTIVITY FORM AND PARENTS’ CONSENT FORM

Name of Institution: Name of Activity:
____________________________________________________ Mindanao Psychology Convention 2024

Inclusive Date(s) of Activity: Venue/Destination:

January 23, 2024 - January 25, 2024 XUGS and XU Main Campus
INSTRUCTIONS:
1. Accomplish and submit this Off-campus Activity Form and Parents’ Consent Form via the provided Google Form Link.
2. All participants must provide a physical copy upon arrival, duly signed physically by their parent/s or legal guardian/s. E-
signature is accepted only for the Google Form Link submission.
3. Accomplish with the legally correct and truthful information only.

COMPLETE LIST OF PARTICIPANTS IN THE OFF-CAMPUS ACTIVITY

(Should only reflect the names who attached their parents' consent form. Add rows if necessary).
COMPLETE NAME OF THE PROGRAM AND PARTICIPANT PARENT/GUARDIAN’S PARENT/
PARTICIPANT YEAR LEVEL ACTIVE MOBILE COMPLETE NAME GUARDIAN’S
NUMBER ACTIVE MOBILE
NUMBER

AGREEMENT:
We, aware of the risks and benefits entailed by our activity take
upon ourselves the responsibility of ensuring the welfare and
safety of everyone participating in our off-campus activity.
I hereby agree to accompany the students mentioned above in their
off-campus activities. As moderator/ duly designated representative
of the University, I acknowledge that I have read and understood
the responsibilities of the accompanying Moderator and assume
full responsibility for the proceedings of the activity.

I hereby certify that the aforementioned organization has

successfully complied with all the requirements set for the
aforementioned off-campus activity set by our
institution/organization.

MX. JUAN A DE LA CRUZ MX. JUAN A DE LA CRUZ

Name and Signature of Organization President/Representative Name and Signature of Moderator/ Representative
 PARENTS’ CONSENT FORM

CONDITIONS AND TRAVEL AGREEMENT:

In connection with my participation in the aforementioned activity and destination, I agree with and abide by the rules and
regulations set and imposed by the University for my safety and the welfare of everyone participating in the off-campus activity.
1. No riding on the top load or boarding platform of the vehicle.
2. Male and female students must be housed in separate rooms.
3. Strictly no smoking and drinking of alcoholic beverages during the activity.
4. No Gambling.
5. Strict observance of the curfew imposed by my Moderator/Faculty supervisor (for stay-in/out-of-town activities).
6. All other provisions for the security and safety of participants are stated in the Implementing Guidelines for Off-Campus
Activities.

Further, I hereby warrant and represent that:

1. I am voluntarily participating in the aforementioned activity;
2. I certify that I am in good physical health and physically able to participate in the described activity;
3. I acknowledge that I have discussed my travel and my participation with my parents/legal guardian who in turn gives
his/her full consent for my participation in the activity;
4. I shall strictly follow/abide by the duly approved schedule of our trip; In the event that unavoidable circumstances occur
and that changes are made in the schedule at the discretion of my organization, I shall immediately notify my
parents/guardian of these changes;
5. I shall not deviate from the established and approved itinerary during the entire duration of the activity; In the event that I
am permitted by my parents to stay behind/ proceed to another destination after the activity, I declare that the University
is no longer responsible for me; Further, I acknowledge that I am solely responsible for my actions and safety once I am
already left on my own; (parents must write these remarks below)
6. In the event that I am allowed by my parents to use/drive my vehicle or ride in a vehicle used by a co-participant of the
activity, I shall travel in convoy with the main vehicle loading all other participants; (parents must write these remarks
below)
7. I shall respect the duly designated school official (faculty/ staff member) who shall represent the University in the
enforcement of the guidelines stated herein and in the implementing guidelines for off-campus activities; and
8. Finally, I recognize the authority of the University to impose sanctions on me for any misrepresentation and for failure to
abide by the rules and regulations for off-campus activities.

I, COMPLETE NAME OF PARTICIPANT, have read, understood, and fully acknowledge full acceptance and conformity with
the stipulated conditions as a participant in the MINDANAO PSYCHOLOGY CONVENTION 2024 on JANUARY 23, 2024,
to JANUARY 25, 2024, to be held at XAVIER UNIVERSITY - ATENEO DE CAGAYAN with primary address at
CORRALES AVENUE, CAGAYAN DE ORO CITY–9000, PHILIPPINES, and XAVIER UNIVERSITY GRADE
SCHOOL - MACASANDIG CAMPUS as our official housing facility that will be used for the said activity.

I, COMPLETE NAME OF PARENT/GUARDIAN, grant my full consent to COMPLETE NAME OF PARTICIPANT, to

participate in the MINDANAO PSYCHOLOGY CONVENTION 2024 on JANUARY 23, 2024, to JANUARY 25, 2024, to be
held at XAVIER UNIVERSITY - ATENEO DE CAGAYAN with primary address at CORRALES AVENUE, CAGAYAN
DE ORO CITY–9000, PHILIPPINES, and XAVIER UNIVERSITY GRADE SCHOOL - MACASANDIG CAMPUS as
their official housing facility that will be used for the said activity. Further, I have read, understood, and denote full acceptance
and conformity with the conditions stipulated in this consent form.