STUDENT WAIVER FORM

ACTIVITY

TEACHER IN-CHARGED:

DATE :
LORIGEN M. PATERNO

TIME :
VENUE

NAME OF STUDENT : ________________________________________________________

ADDRESS :_________________________________________________________________
I am allowing my daughter/son to participate in the above-mentioned activity. I will
not hold the school responsible for any untoward incident that may take place.
NAME & SIGNATURE OF PARENT/GUARDIAN :
______________________________________________
CONTACT NUMBER : __________________________ ADDRESS :
_______________________________

STUDENT WAIVER FORM

ACTIVITY

TEACHER IN-CHARGED:

DATE :
LORIGEN M. PATERNO

TIME :
VENUE

NAME OF STUDENT : ________________________________________________________

ADDRESS :_________________________________________________________________
I am allowing my daughter/son to participate in the above-mentioned activity. I will
not hold the school responsible for any untoward incident that may take place.
NAME & SIGNATURE OF PARENT/GUARDIAN :
______________________________________________
CONTACT NUMBER : __________________________ ADDRESS :
_______________________________

STUDENT WAIVER FORM

ACTIVITY

TEACHER IN-CHARGED:

DATE :
LORIGEN M. PATERNO

TIME :
VENUE

NAME OF STUDENT : ________________________________________________________

ADDRESS :_________________________________________________________________

I am allowing my daughter/son to participate in the above-mentioned activity. I will

not hold the school responsible for any untoward incident that may take place.
NAME & SIGNATURE OF PARENT/GUARDIAN :
______________________________________________
CONTACT NUMBER : __________________________ ADDRESS :
_______________________________

Date :
To : The MSU-IIT Administration
Through : The adviser concerned
This is to authorize my son/daughter/sister/brother/lodger/ward to attend the
following activity;
Students Name : _______________________________ Activity :
_____________________________
Venue & Address : ______________________________ Date :
_______________________________
Adviser/Chaperone : ____________________________ Position :
_____________________________
I understand that my son/daughter/sister/brother/lodger/ward will pay the
total amount of Php________________ as payment for participating/attending the said
activity.
Signature Over Printed Name :
__________________
Relationship to the Student :
___________________