Republic of the Philippines

POLYTECHNIC UNIVERSITY OF THE PHILIPPINES

,
Office of the Vice President for Branches and
Campuses
TAGUIG BRANCH

WAIVER/UNDERTAKING

We,____________________________(student) and_____________________ (parent/guardian),

hereby execute this Waiver/Undertaking to hold the Polytechnic University of the Philippines
and the__________________________free from any liability for any injury / illness / loss of life
or property that may be incurred/ sustained by the student in the course of his/her participation
on the____________________________________________________________provided that
the same is not due to any willful criminal act or gross negligence of the training institution or
any of its representatives, officers or employees.

As the parent/guardian of the student, I hold myself responsible for any expenses that may be
incurred as a result of the student’s illness, injury, death or loss or property in the course of the
student’s particiapation on the________________________________________________,
except as provided above. I further undertake to be responsible for any breakage, loss of
property, damage, death or injury that may be caused by the student to any party while
participating the said event.

We execute this Waiver/Undertaking in accordance with our free will, realizing the benefits that
the student shall obtain from the said event.

_________________________________ _________________________
(Printed Name and Signature of (Printed Name and Signature of
Student) Parent/ Guardian)

REPUBLIC OF THE PHILIPPINES )

CITY OF _____________________ )

Subscribed and sworn to before me affiants exhibiting valid proofs of their identity as
follows:

NAME ID No. Issued at/on

_______________________ ____________________ _____________________

_______________________ ____________________ _____________________

They acknowledge to me that the foregoing Waiver/ Undertaking was executed in

accordance with their own free will.

NOTARY PUBLIC

Doc No. _______;

Page No. _______;
Book No. _______;
Series of ________.

Gen. Santos Ave. Lower Bicutan, Taguig City 1772; (Direct Line) 837-5858 to 60; (Telefax) 837-5859; website:
www.pup.edu.ph e-mail: taguig@pup.edu.ph

“THE COUNTRY’S 1st POLYTECHNICU”