PARENTAL CONSENT AND WAIVER FORM

I, ______________________________________, grant permission for my son/daughter

____________________________ to participate in the film viewing entitled “Boses” which requires
transportation to a location away from the school site. This activity will take place under the guidance
of the teachers and SSG officers of Baruya High School.

A brief description of the film viewing follows:

Location of event: SM Cinema City of San Fernando

Date and estimated time of arrival/departure: August 16, 2015 6:30 AM

August 16, 2015 5:00 PM

Mode of transportation: Public Utility Jeepney

I, as parent and/or legal guardian, remain legally responsible for any personal actions taken by
the above named participant.

I agree in behalf of myself, my child named herein, or our heirs, successors and assigns, to hold
harmless and defend Baruya high school, its teachers and officers or representative associated with the
event, from any and all actions, claims, demands, damages, costs, expenses and all consequential
damage arising from or in connection with my child attending the event or in connection with any illness
or injury or cost of medical treatment in connection therewith.

In signing the Parental Consent and Waiver, I am not relying on any oral or written
representation or statements made by the school, its faculty members and officers associated with the
event, to induce me to permit my student to join the film viewing, other than those set out in this
Consent and Waiver.

I am 18 years of age or more and have read and understand the terms of this consent and
waiver, and recognize that it is binding upon me.

_____________________________ Date: ____________________

Parent/Guardian over Printed Name

Home Address
_____________________________

Contact Number
_____________________________