REVISION NO.: 03 REVISION NO.

: 03
REVISION DATE: August 14, 20 18
REVISION DATE: August 14, 20 18

ACTIVITY INFORMATION & CONSENT ACTIVITY INFORMATION & CONSENT

IMPORTANT INFORMATION IMPORTANT INFORMATION
 THIS FORM SHOULD BE FILLED -OUT BY THE PROPONENT(S) OF THE SERVICE-LEARNING OR CO MMUNITY ENGAGEMENT  THIS FORM SHOULD BE FILLED -OUT BY THE PROPONENT(S) OF THE SERVICE-LEARNING OR CO MMUNITY ENGAGEMENT
INITIATIVE OR BY CSCE. INITIATIVE OR BY CSCE.
 THIS FORM SHOULD BE DULY ACCOMPLISHED BEFORE THE ACTUAL CONDUCT OF THE FIELDWORK ACTIVITY RELATED TO A  THIS FORM SHOULD BE DULY ACCOMPLISHED BEFORE THE ACTUAL CONDUCT OF THE FIELDWORK ACTIVITY RELATED TO A
SERVICE-LEARNING OR CO MMUNITY ENGAGEMENT INITIATIVE. SERVICE-LEARNING OR CO MMUNITY ENGAGEMENT INITIATIVE.
 USE THE SPACE PROVI DED FOR REMARKS TO INDICATE SPECIAL INSTRUCTIONS / REQUESTS / IMPORTANT INFORMATION /  USE THE SPACE PROVI DED FOR REMARKS TO INDICATE SPECIAL INSTRUCTIONS / REQUESTS / IMPORTANT INFORMATION /
REQUIREMENTS BY CO NCERNED INDIVIDUALS. REQUIREMENTS BY CO NCERNED INDIVIDUALS.

TITLE OF SERVICE-LEARNING / TITLE OF SERVICE-LEARNING /

COMMUNITY ENGAGEMENT INITIATIVE COMMUNITY ENGAGEMENT INITIATIVE

DATE(S) & TIME(S) OF THE ACTIVITY DATE(S) & TIME(S) OF THE ACTIVITY

LOCATION LOCATION

FACULTY / EMPLOYEE / FACULTY / EMPLOYEE /

FACILITATOR-IN-CHARGE FACILITATOR-IN-CHARGE

DECSRIPTION OF THE ACTIVITY DECSRIPTION OF THE ACTIVITY

REMARKS REMARKS

Signature over Printed Name of Student Signature over Printed Name of Student
(include course & section for (include course & section for
SL/NSTP activities) SL/NSTP activities)

I, the undersigned, have reviewed all of the above information and have approved of I, the undersigned, have reviewed all of the above information and have approved of
the details and itinerary. I am aware of the risks inherent in participating in this activity . I the details and itinerary. I am aware of the risks inherent in participating in this activity . I
hereby give my permission for my son/daughter to participate in this activity. hereby give my permission for my son/daughter to participate in this activity.

SIGNATURE OVER CONTACT SIGNATURE OVER CONTACT

PRINTED NAME OF DETAIL(S) OF PRINTED NAME OF DETAIL(S) OF
PARENT / GUARDIAN PARENT / PARENT / GUARDIAN PARENT /
AND DATE SIGNED GUARDIAN AND DATE SIGNED GUARDIAN

COPY: (1) PARENT OR GUARDIAN; (2) CSCE CSCE-040A/B-04 COPY: (1) PARENT OR GUARDIAN; (2) CSCE CSCE-040A/B-04

THIS FORM IS AVAILABLE AT THE CENTER FOR SERVICE-LEARNING AND COMMUNITY ENGAGEMENT. THIS FORM IS AVAILABLE AT THE CENTER FOR SERVICE-LEARNING AND COMMUNITY ENGAGEMENT.