PAMANTASAN NG LUNGSOD NG PASIG

Alcalde Jose St., Kapasigan, Pasig City

COLLEGE OF NURSING

R E L A T E D L E A R N I N G E X P E R I E N C E ( R L E )
ASSUMPTION OF RISK, RELEASE AND WAIVER OF LIABILITY, AND INDEMNITY AGREEMENT

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Read this document completely and carefully before signing. Its effect is to
release the Pamantasan ng Lungsod ng Pasig and its representatives from any
liability resulting from your participation in the activities described below, and to
waive all claims for damages or losses against the University, its representatives,
and the institutions where you will have your Related Learning Experience for
any untoward events that may arise from such activities. It also confirms your
responsibility to comply with the University’s policies and procedures as well as
local and state regulations.
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The College of Nursing in its commitment to provide best and quality nursing education
and as part of the curriculum prescribed by the Commission on Higher Education
(CHED), the students under the program Bachelor of Science in Nursing should
undergo RLE (Related Learning Experience) in several clinical areas like but not limited
to in-patient service wards (medicine, obstetrics, pediatrics, and surgery), operating
room, delivery room, intensive care unit, emergency room, barangay health
centers/stations, City Disaster Risk Reduction and Management Office - Pasig
Emergency Unit, San Lazaro Hospital, Philippine Orthopedic Center, and National
Center for Mental Health.

During the tour of duty,

Assumption of Risks. The University and the College of Nursing have instituted
guidelines for the students to follow during the RLE including the reduction of risks and
spread of infections; however, the University cannot guarantee that I will not become
infected with any communicable disease or be inflicted with any other injury/ies. I
acknowledge the nature of work of nurses in the clinical field and I should be oriented
and trained of such. I understand the risks voluntarily assume the risk that I may be
exposed to or infected by any communicable diseases by using the Facility and
participating in the Activity and that such exposure or infection may result in personal
injury, illness, permanent disability, and death. I understand that the risk of becoming
exposed at the Facility that may result from the actions, omissions, or negligence of
myself and others, including, but not limited to, other participants.

I voluntarily assume all the foregoing risks and accept sole responsibility for any injury
to myself (including, but not limited to, personal injury, disability, and death), illness,
damage, loss, claim, liability, or expense, of any kind, that I may experience or incur in
connection with my use of the Facility and participation in the RLE.

I have read the previous paragraphs and I know, understand, and appreciate
these and other risks that are inherent in the Related Learning Experience.

Release of Liability. That the University, the College of Nursing, and the assigned
faculty/clinical instructor, and the institution I am assigned at will be held free of liability
from any damage or injury/death of third person resulting to my negligence, malpractice,
and/or intentional acts. That University, the College of Nursing, the assigned
faculty/clinical instructor, and the institution I will be assigned at will be held free of
liability from any damage, injury, or death I may suffer resulting from any untoward
incident that may happen in the course of my duty.
Indemnification and Hold Harmless. I also hereby agree to indemnify, defend, and
hold the releasees harmless from any and all claims, actions, suits, procedures, costs,
expenses, damages, and liabilities including, but not limited to, attorney’s fees, arising
from, or in any way related to the participation in the Related Learning Experience,
except for those arising out of the willful misconduct, gross negligence or intentional
torts, as applicable.

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Acknowledgment of Understanding. I have read this assumption of risk, release and
waiver of liability, and indemnity agreement, and have had the opportunity to ask
questions about the same. I fully understand this assumption of risk, release and waiver
of liability and indemnity agreement, that I am giving up substantial rights in connection
therewith, and that its terms are contractual, and not a mere recital. I acknowledge that I
have signed this agreement freely and voluntarily.
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_______________________________ ________________________________
Name of Student Name of Parent/guardian

__________________ __________ __________________ __________

Signature Date Signature Date