IMMACULATE CONCEPTION ACADEMY, INC.

Gov. D. Mangubat Ave., Pasong Lawin, Burol Main, City of Dasmariñas, Cavite 4114
(046) 416-3636 / www.ica-dasmarinas.edu.ph

PARENT CONSENT AND WAIVER FORM

Date Filed: ________________________________

GENERAL INFORMATION OF ACTIVITY

ORGANIZATION SPONSORING THE ACTIVITY: TITLE/NAME OF ACTIVITY: Mr. and Ms. ICA Coronation Night

VENUE: (Please put a check mark on the type of activity that

this waiver applies.)  Co-curricular (Student activities related to academic requirements)
 Within ICA Campuses  Extra-curricular (Student activities not related to academic requirements)
 Outside Campus
MODE OF TRANSPORT
 Leadership Training Seminar
 Official School Transport  Others  Community Outreach Activities
Please specify:  Recreational Activities
 Private Transport _______________________  Seminar/Conference/Convention
 Volunteer Work
 Rented Vehicle  Team Building
 Competition/Contest
 Commute via Public Utility Vehicle  Sports & Athletic Activities
(Bus, Jeepney, Van, Train, Airplane, Ship and the like.)  Others:
Please specify __________________________________________

OBJECTIVES OF THE ACTIVITY

AMOUNT OF FEES TO BE COLLECTED FROM THE none

PARTICIPANT

DATE OF THE ACTIVITY April 12, 2024 Friday

ICA South Campus Gynasium
ADDRESS/VENUE OF THE ACTIVITY

TIME AND PLACE OF DEPARTURE 5:00PM Onwards ICA South Gymnasium

TIME AND PLACE OF ARRIVAL 9:00PM ICA South CAmpus

FACULTY/ADVISER/SCHOOL OFFICIAL-IN-CHARGE
TO BE WITH THE STUDENTS FOR THIS ACTIVITY
CONTACT NUMBER OF PERSONNEL-IN-CHARGE
FOR THIS ACTIVITY

NOTE:
1. Please fill up all the details requested. Incomplete forms will not be credited.
2. Write legibly in the spaces provided.
3. Submit together with this form the photocopy of any government issued identification card of the parent/guardian signatory.
4. Submit the completed form to the Guidance Office a week before the scheduled activity.
 IMMACULATE CONCEPTION ACADEMY, INC.
Gov. D. Mangubat Ave., Pasong Lawin, Burol Main, City of Dasmariñas, Cavite 4114
(046) 416-3636 / www.ica-dasmarinas.edu.ph

PARENT CONSENT AND WAIVER FORM

Date: __________________________

To the Guidance Office,

As parent/guardian of ____________________________ ____________ ___________ _____________

Full Name of Student Student Number Year Level Section

I voluntarily allow my son/daughter/ward to join and participate in the ________________________________

Title of the Activity

to be held on _____________________________________ at _____________________________________.

Date of Activity Venue of Activity

Together with my child, I present this signed document to personally express my willful understanding
of the terms and conditions stated in this form and that Immaculate Conception Academy and its officers,
faculty advisers and staff are expected to observe legal diligence expected of them for the safety and security
of my child for the entire duration of the activity from departure and to the expected arrival.

This legal diligence would include oral and/or written instruction given to the student within the
reasonable time whether before or during the activity, that could ensure his/her safety and security.

In the event that my child disregards the instructions or acted on his/her own volition otherwise
without informing the personnel-in-charge I, as the parent/guardian shall therefore understand and shall have
no claims against Immaculate Conception Academy, to the officers of the institution, faculty advisers and staff.

Respectfully yours,

Printed Name of Guardian/Parent Signature Contact Details

Printed Name of Student Signature Contact Details

NOTE:
1. Please fill up all the details requested. Incomplete forms will not be credited.
2. Write legibly in the spaces provided.
3. Submit together with this form the photocopy of any government issued identification card of the parent/guardian signatory.
4. Submit the completed form to the Guidance Office a week before the scheduled activity.
 IMMACULATE CONCEPTION ACADEMY, INC.
Gov. D. Mangubat Ave., Pasong Lawin, Burol Main, City of Dasmariñas, Cavite 4114
(046) 416-3636 / www.ica-dasmarinas.edu.ph

PARENT CONSENT AND WAIVER FORM

NOTE:
1. Please fill up all the details requested. Incomplete forms will not be credited.
2. Write legibly in the spaces provided.
3. Submit together with this form the photocopy of any government issued identification card of the parent/guardian signatory.
4. Submit the completed form to the Guidance Office a week before the scheduled activity.