OSA Form 06

University of Science and Technology of Southern Philippines

Alubijid | Cagayan de Oro | Claveria | Jasaan | Oroquieta | Panaon

PARENT/GUARDIAN CONSENT REQUEST FORM

_____________________
Date
College of _______________________
Department of ____________________

TO WHOM IT MAY CONCERN:

This is to certify that I allowed my son / daughter / ward to join the Educational
(Please specify the name of event/activity here)

Name of son / daughter

Name of Activity/event
Inclusive Date/s of Activity/event
Place(s) to Visit
For OJT (Please Write the name
of Company/Industry)
Thank you very much!
Yours truly, APPROVED:
______________________________ __________________________
Name of Student Name of Parent/ Guardian
(Signature-Over-Printed Name) (Signature-Over-Printed Name)

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Acknowledgement
I,___________________________________ (name) presently enrolled in ___________________
______________ (course/ year & section) present myself to join the _________________________as
part of our school / student activity and

1. Do hereby pledge to obey and abide the rules and regulations promulgated, enforced by the officials of the
University for the protection and safety of all;
2. That I understand that should I violate the guidelines and policies, that I be dealt with accordingly.
3. That should I have clarifications regarding the activity/event, it is my responsibility to inquire from concerned
authorities/organizers.

Thank you very much!

Yours truly, Noted by:

______________________________ __________________________
Name of Student Name of Parent/ Guardian
(Signature-Over-Printed Name) (Signature-Over-Printed Name)

Copies for Distribution:

1. College file
2. Office of the Stunt Affairs
3. Student file

SUBSCRIBED AND SWORN to before me this_____ day of _______,____ in the City of Cagayan de Oro .

Note: for off-campus activities/OJT

please have this form notarized before
submitting to OSA with the SARF (for
Student Orgs Only) and other required
documents.