POLYTECHNIC UNIVERSITY OF THE PHILIPPINES

SANTA MARIA CAMPUS

PULONG BUHANGIN, SANTA MARIA, BULACAN

PARENT/GUARDIAN CONSENT REQUEST FORM

Date: _______________

TO WHOM IT MAY CONCERN:

This is to certify that I allowed my son or daughter to be part of the main activity in PUPSMB

Name of son or daughter

Name of Activity Graduation ball 2017
Date of Activity April 24, 2017
Time 5:00 PM
Amount Six hundred pesos only (P600.00)

Thank you very much!

Yours truly, APPROVED BY:

______________________________ ______________________________
Name of Student Name of Parent/Guardian
(Signature Over Printed Name) (Signature Over Printed Name)

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STUDENT WAIVER
I, ______________________________ (Name of Student) presently enrolled in ____________________
(Course/Year & Section) present myself to join the ________________________ as part of our main
activity in PUPSMB and do hereby pledge that:

1. I will obey and abide the rules and regulations promulgated, given to us by the University

2. That I hereby waived and renounce my rights to all damages and I will not hold the University
leaders, faculty teachers and staff of the school of responsible for any misfortune, injury, or
accident be slight or serious, that may happen in connection with the activities or
requirements. The cause of which will be attributable to my acts of disobedience, negligence,
and the offense of my heading to advice, warning, precaution and safety rules that were read
to me by the faculty teacher/s before the start of the activity.

That the content of this waiver was read and explained to me before I affix my name and signature this
_____ day of __________ freely and voluntarily.

Thank you very much.

Yours truly, APPROVED BY:

______________________________ ______________________________
Name of Student Name of Parent/Guardian
(Signature Over Printed Name) (Signature Over Printed Name)