STUDENT AFFAIRS SERVICES

PARENT/GUARDIAN CONSENT FORM (PGCFO)

(For Off-Campus Activities)
Name of Student: Course/Year level ID Number

Title of the Activity:

Place of the Activity: Registration Fee:

Departure Date: Departure Time:

Arrival Date: Arrival Time:

RESPONSIBLE DEPARTMENT
Department/Office Unit: UPH Molino, College of Arts Landline: 046-577-0602
and Sciences/NSTP Department

Personnel In-Charge: MICHELLE A. VINCOY – NSTP Mobile Number: 09674000353

COORD.

Dean/Immediate Supervisor: Dr. John Robby Robinos, LPT Mobile Number:

CONSENT
1. I understand that UPH-Molino together with its administrators, faculty, and staff did everything
with due diligence to ensure the safety of my son/daughter during the conduct of the activity.

2. I understand that due diligence means that all documentation was properly done including the
oral and written instruction during meetings and consultation among the group of students
including my son/daughter.

3. To ensure the safety of all the participants, I know that each has a responsibility to listen
carefully to the instructions of the faculty-in-charge and to follow all guidelines and ground rules
during the conduct of the activity which includes my son/daughter.

4. We understand that the activity is not compulsory/mandatory and an alternative activity can be
done if ever my son/daughter will not join the activity.

5. We voluntarily allow our son/daughter to join the activity and needs to adhere to all the safety
measures being done by the administrator, faculty and staff of UPH Molino.

6. The activity is for the enhancement of skills of my son/daughter and we need to pay for a
certain amount to cover transportation and ammunition expenses.

7. Please put a check on the blank provided:

_________I am allowing my son/daughter to get off at _______________________which is near
to our residence, after the activity.
_________I am not allowing him to get off in any place except inside the school wherein we will
pick him/her up after the activity.

UPHMO-SAS-SP-ADM-4103.1/rev0 Parent/Guardian Consent Form-Off Campus (PGCFO)

 STUDENT AFFAIRS SERVICES

_________________________________
(Printed Name & Signature of parent/guardian)
student)
Address:_________________________________
Mobile Number:___________________________
________________________________
(Printed name and signature of
Address:_________________________
Mobile Number:__________________

UPHMO-SAS-SP-ADM-4103.1/rev0 Parent/Guardian Consent Form-Off Campus (PGCFO)