PSE Application No.:
________________
Date Application Rec’d:
____________________
S.E. Approval No.:
____________________
Date Approved:
____________________
__
UNIVERSITY OF CAGAYAN VALLEY
UCV-OOP-F008
TUGUEGARAO CITY
____________________________________________________
(COLLEGE)
STATEMENT OF PARENTAL CONSENT
Dear Parents/Guardians:
Your son/daughter has expressed her intentions of joining the
(TITLE OF ACTIVITY OR EVENT)
Sponsored by the _________________________________________________________________to be held on
(NAME OF SPONSORING ORGANIZATION)
_____________________________________at_____________________________________________.
(DATE OF ACTIVITY)
(PLACE)
Should you allow your son/daughter to join the aforementioned activity, kindly fill up the Reply Slip
below and return the same to the Adviser or Supervising Instructor of ________________________________
(CLASS / ORGANIZATION)
________________________on or before_________________________________________.
(DEADLINE FOR SUBMISSION OF WAIVERS)
Rest assured that Adviser / Supervising instructor will accompany them during the activity. Should there be a
need for you to communicate with your son/daughter, kindly call:
__________________________________
Sincerely yours,
CONTACT # OF ADVISER/SUPERVISING INSTRUCTOR
SIGNATURE OVER PRINTED NAME OF THE ADVISER OR
SUPERVISING INSTRUCTOR
------------------------------------------------------------------------------------------------------------------
REPLY SLIP
Please be informed that the undersigned poses no objection to the participation of my son / daughter
____________________________________________________________________________________ in the
(NAME OF SON / DAUGHTER)
___________________________________________________________________________ sponsored by the
(TITLE OF ACTIVITY OR EVENT)
______________________________________________________________________ to be hold on
(CLASS / NAME OF SPONSORINGORGANIZATION)
________________________________at _______________________________________________________.
(DATE OF ACTIVITY)
(PLACE)
I hereby give consent for him/her to take part in the said event.
PSE Applicant No.
______________
Date Applicant Rec’d:
SIGNATURE OVER PRINTED NAME OF THE PARENT/GUARDIAN
__________________
Date: _______________________
S.E. Approval No.:
Contact No. of Parent’s Guardian: _______________________________
__________________
Address: ___________________________________________________
Date Approved:
___________________________________________________
__________________
_
___________________________________________________
(Note: Filled-up parental Consent should be checked by the Dean (for Curricular or Co-Curricular Off-campus Activities) or the Director
for Student Affairs (Extra-Curricular Off-campus Activities) then, kept by Adviser or Supervising instructor. Students who did not
submit their filled –up waivers are not allowed to join the off-campus activity.)
Issue date: April2008
Revision Status:1
UCV-OP-F009
WAIVER AND RELEASE OF LIABILITY
PSE Application No.:
_______________
(This form is to be returned to your sponsoring organizer before you can attend/participate in any off-campus activity.
The purpose of this form is to inform you of certain risk and responsibilities that you will be assuming while you will be
participating in such activity. Please read the form carefully before signing).
Date Application Rec’d:
_______________
S.E. Approval No.:
___________________
Date Approved:
___________________
l. Activities and Associations
University of Cagayan Valley makes no representation or recommendation regarding any risk involved in
activities outside the School. Furthermore, the school assumes no responsibility or liability for personal or property
injuries caused by the student, resulting from the student’s participation in those activities.
II. Health and Safety
Students and other participants are responsible for providing their own health insurance. Students are required to follow all instructions and
safety procedures provided by the supervising instructor/s. Students are also required to strict/abide by the rules and regulations even off-campus,
including the Student Code of Conduct.
lll. Transportation
University of Cagayan Valley is not liable for any injury/ies to person/s or property/ies caused by the act/s or omission/s of others during
transportation. Furthermore, the School makes no recommendations or guarantees to any transportation providers you may deal with in your
arrangements.
IV. Students Responsibilities
As a participant, I agree to:
a.
Participate in all learning activities;
b. Consult with the supervising instructor or staff there are changes, problems, or concerns with the activity;
c.
Complete required paperwork to include but not limited to a daily log of the activity and evaluation of the activity.
SUMMARY
I understand that there are certain dangers, hazards and risks in the above-stated activity. I understand that University of
Cagayan Valley assumes no responsibility for any Injury/ies, death or damage resulting from these dangers, hazards and risks. I
understand that the School in no way represents, or acts as a agent, for the operation or management of any means of transportation,
facilities or other suppliers of goods and services used by or during the activity. I fully understand that the School assumes no
responsibility for any injury/ies, loss, death, damage or accident, delay or other irregularity, which may be caused by any supplier of any
goods or services use or during the activity. I also understand that the School is not responsible for any losses or expenses due to
weather, strikes, hostilities, wars, natural disasters, terrorism or other such causes.
I fully and finally release from any all liability, claims demands, and causes or action and covenant not to sue or cause to be
sued in any judicial or administrative forum, the School, Its officers, agents and employees with respect to any and all matters relating to
or arising out from my participation in the activity. I understand that this Waiver and Release of Liability may not be modified or waived
except by a written document signed by me and a duly authorized representative of the School.
I warrant that at least I am 18 years of age as of the date I have signed this document. If under the age of 18 years, the parent
or legal guardian of such participant in behalf of the participant must also sign below.
I understand that the terms and provisions of this document are severable. If, for any reason, one or more terms of this
document are unenforceable, illegal or in conflict with any law governing this document, the validity of the remaining portions of this
document shall not be affected.
I acknowledge that, prior to signing this waiver and Release of Liability, I read this document, and I understand its terms and
conditions, and voluntarily execute it with the understanding that University of Cagayan valley shall rely on the statements and
warranties contained herein. I further understand that this document binds my estate, heirs, assigns and me.
Student No.
PRINTED NAME OF PARTICIPANT (Last name, First name M.I.)
Course/Yr. Level
Name of Faculty/Staff Advisor(s) or Supervisor(s) Assigned:
Location(s) and Date(s) of Activity/ies:
Purpose/s of Activity/ies:
In case of emergency: (include Names, Addresses and Relevant Phone Numbers)
Signature of Participant
Date
If participants is below 18 years of age, printed Name of Parent or Legal Guardian
Signature of Parent or Legal Guardian
Issue Date: April 2008
Date
Revision Status : 1