OFFICE OF STUDENT AFFAIRS

PARENTAL GUARDIAN PERMIT FORM

FOR OFF-CAMPUS ACTIVITIES

To be accomplished in duplicate. One copy to be retained by the parent/guardian; the other copy for
Wesleyan University-Philippines.

Name of Student ID Number

Name of Activity

Place of Activity

Departure Date Departure Time

Arrival Date Arrival Time

College /Department/ Office / Unit

Faculty/Staff In-Charge Immediate Supervisor

(Signature over printed name) (Signature over printed name)
Contact number: Contact number:

PERMISSION
1. Together with my son/daughter, I know that the University and its officers, faculty, and staff
are expected to exercise the legal diligence required for the safety and well being of my child
for the duration and the place, date, and time of the activity as stated.
2. The legal diligence would include oral and written instruction, whether given before or during
the activity, that if followed, would ensure the safety of my son/daughter.
3. If my son/daughter disregards or fails to follow these instruction or should act on his/her own, I,
together with my son/daughter, shall have no claims against the University, its officers,
faculty/staff-in-charge should any damage be caused or liability be incurred to property or
person.
4. (For academic-related activity) We understand and affirm that this activity is not
compulsory/mandatory. We understand that other requirements of comparable academic
weight may be imposed on my son/daughter in lieu of this activity.
5. Please allow my son/daughter to get off at
Which is near our place of residence, after the activity. My son/daughter shall take full
responsibility of him/her upon disembarking your designated transportation.

Parent/Guardian Student
(Signature over printed name) (Signature over printed name)
Contact number: Contact number:

ACAD-SPS-OSA-FM-020 Rev 0 Effective 15 Nov 2021