16th Regional Mid-Year Convention

WAIVER
NAME: _____________________________________________________________________________________
UNIVERSITY/YEAR/COURSE: _____________________________________________________________
EMERGENCY INFORMATION:
CONTACT PERSON 1:_______________________________ CONTACT #: ______________________
CONTACT PERSON 2:_______________________________ CONTACT #: ______________________
MEDICAL INFORMATION:
List all the ailments your child suffers from:
_____________________________________________________________________________________________
List any medication your child might need:
_____________________________________________________________________________________________
Indicate any allergies with certain medication:
_____________________________________________________________________________________________
I take responsibility for my childs whereabouts after this activity.
I agree to waive release, guarantee and hold harmless the NFJPIA-Region 1 and CAR, its
officers, advisers, members, and all the organizers of this event from any claims of
liability arising out of my childs participation in this activity. I also agree to waive that
NFJPIA-Region 1 and CAR, its officers, advisers, members and all organizers of this event
has responsibility to my child only within the grounds of the venue.
Should my child require medical attention as result of accident or serious illness, I do
hereby grant and bequeath upon the organizers of this event permission and authority
for and on my behalf to authorize any licensed medical practitioner to render medical
aid and treatment.
CONFORME:

_______________________________ _____________________
SIGNATURE OVER NAME DATE

NOTE: Non presentment of this waiver during the

registration proper shall be charged P100.00.