Republic of the Philippines

Laguna State Polytechnic University

Province of Laguna
WAIVER
Date:_______________
To whom it may concern:
As the parent/guardian of ___________________________________________________________
(Name of Student)
Department/Unit Sponsoring Activity:__________________________________________________
Nature of Activity :________________________________________________________
Date of Activity :________________________________________________________
Place of Activity :________________________________________________________
Time of Activity :________________________________________________________
Faculty/Adviser/Staff-in-Charge:_______________________________________________________
Together with my child, I know that Laguna State Polytechnic University and its officers, faculty, and staffs 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.
This legal diligence would include oral or written instructions whether given before or during the activity, that if
followed, would ensure the safety of my child.
If my child disregards or fails to follow those instructions or should act on his/her own, I together with my child,
shall have no claims against the school, its officers, faculty, adviser, staff-in-charge should any damage be caused or liability
be incurred to property or person.
Respectfully yours,
____________________________________ Contact number:_________________
Signature over Printed Name
of Parent/Guardian
____________________________________ Contact number:_________________
Signature over Printed Name
of Student
LSPU-OSAS-SF-010 Rev.0 10 August 2016

Student Copy
Republic of the Philippines
Laguna State Polytechnic University
Province of Laguna
WAIVER
Date:_______________
To whom it may concern:
As the parent/guardian of __________________________________________________________
(Name of Student)
Department/Unit Sponsoring Activity:__________________________________________________
Nature of Activity :________________________________________________________
Date of Activity :________________________________________________________
Place of Activity :________________________________________________________
Time of Activity :________________________________________________________
Faculty/Adviser/Staff-in-Charge:_______________________________________________________
Together with my child, I know that Laguna State Polytechnic University and its officers, faculty, and staffs 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.
This legal diligence would include oral or written instructions whether given before or during the activity, that if
followed, would ensure the safety of my child.
If my child disregards or fails to follow those instructions or should act on his/her own, I together with my child,
shall have no claims against the school, its officers, faculty, adviser, staff-in-charge should any damage be caused or liability
be incurred to property or person.
Respectfully yours,
____________________________________ Contact number:_________________
Signature over Printed Name
of Parent/Guardian
____________________________________ Contact number:_________________
Signature over Printed Name
of Student
LSPU-OSAS-SF-010 Rev.0 10 August 2016