B i c o l U n i v e r s i t y Legazpi City, Philippines Parents’ /Guardians’ Permit Form _____ semester, SY ______________ PLEASE TAKE NOTE CAREFULLY 1. Please fill up this form in BLOCK LETTERS. 2. ALL sections MUST BE COMPLETED when applicable. 3. Permit should be duly NOTARIZED for Educational Tour/Field Trip purposes and when participant is a minor. TO WHOM THIS MAY CONCERN This certifies that ____________________________________________, a ________________ (Course and Year) of the College of ____________________________________ with Student No. ___________________ has the permission of his/her undersigned parent(s)/guardian(s) to participate and/or attend in the ______________________________________________________ on ________________, 20 _____ in _______________________. This certifies further that risk assessment plans and necessary safety and precautionary measures have been instituted. Further, that the following faculty members shall accompany him/her in the travel. 1. ___________________________________ _____________________________ 2. ___________________________________ _____________________________ 3. ___________________________________ _____________________________ 4. ___________________________________ _____________________________ Faculty Name (Please print) Faculty Signature Faculty Name (Please print) Faculty Signature Faculty Signature Faculty Name (Please print) Faculty Signature Faculty Name (Please print) Note: If the student is a minor, both parents MUST sign the permission form. I/We have honestly and accurately completed all parts of the Parents’/Guardian’s Permit Form to the best of my/our ability. _________________________________ _________________________________ _________________________________ _________________________________ Parent/Guardian Signature #1 Date Parent/Guardian Signature #2 Parent/Guardian Name (please print) Date Parent/Guardian Name (please print) _________________________________ _________________________________ _________________________________ _________________________________ Complete Address Contact Numbers Complete Address Contact Numbers JURAT On ________, of 20 ___, before me personally appeared, ______________________________ and ___________________________________ to me known to be the individual, or individuals described in and who executed the within and foregoing instrument, and acknowledged that he/she/they signed their free and voluntary act and deed, for the uses and purposes therein mentioned. Given under my hand and official seal this ______ day of _________________, 20 ____. Notary Signature: __________________________ Notary Printed Name : ____________________________ Affix seal here My commission expires: ___________________________ BU OSS Office of Student Services Student Activities Section S A S BU-F-OSS-34 Effectivity: September 13, 2012 Revision No. 1 P. 1 of 1