PARENT/GUARDIAN CONSENT FORM
College:
Campus: Los Baños
Name of Student:
Part 1. Permission to Participate
I have understood the information concerning the payment of 20 pesos and_2KM COLOR SPRINT_ (off-campus
activity) and give my son/daughter, _____________________________________ (name of student),
permission to participate in the said program. I understand the arrangement for the mobility to the
destination. I also understand that my son/daughter must meet the application requirements to be accepted in
the program.
________________________________________ ________________________
Signature of Parent/Guardian over printed name Date
Part 2. Emergency Authorization
In the event that I cannot be reached in an emergency, I give permission to the staff of LSPU or the staff of the
off-campus activity office/unit/agency to secure proper treatment for my son/daughter.
________________________________________ ________________________
Signature of Parent/Guardian over printed name Date
Part 3. Liability
I hereby agree to waive and release any and all rights that I, my child, or our representatives may have to make
claim against LSPU of their respective officers, employees, or representatives arising from injury or damages,
including attorney’s fees, that may result from my child’s participation in the off-campus activity.
I further agree to indemnify and hold harmless the partner/cooperating office/unit/agency or their respective
officers, employees, or representatives from any claims, including attorney’s fees, which I or my child might
make or which might be made on my or our behalf by others, or which might be made against me or my child
by others, arising from my child’s participation in the above-mentioned activity.
________________________________________ ________________________
Signature of Parent/Guardian over printed name Date
SUBSCRIBED AND SWORN TO before me, this ___ day of _____, 2022, exhibiting to me and was identified by
me through his/her competent evidence of identity: _____________________________ issued on
_____________ at ____________________.