COLLEGE OF NURSING

WAIVER

I, parent/guardian of ,
(Parent’s / Guardian’s Name) (Student’s Name)
of the College of Nursing and a resident of
do hereby waive my rights I have under Law for any injury that my son/daughter would suffer or incur
under circumstances beyond human control during the Related Learning Experience Activities
(Activity)
including travel to assigned areas including PNSA week on 2nd Semester AY 2018-2019.
(Activity) (Schedule Date)
Related Learning Experience Activities such as completion of Extension Duties at Base/Affiliating
Hospital (Bukidnon Provincial Hospital – Maramag) assigned Community Area for Community
exposure /services, Adventist Medical Center Valencia in shifting duty AM/PM/NOC, Busco Sugar
Milling Corporation, Inc. for Industrial Nursing, School Nursing & Birthing Home/OPT/TB DOTS in
Rural Health Unit - Maramag and other areas where conduct of nursing activity will be held.
( Related Learning Experience Activities and Place of Destination)

I hereby further absolve the Central Mindanao University and the admitting firm of whatever liability he/she
will encounter under the inclusive dates of the Orientation, Patient Assessment, Clinical Duty,
(Activity)
Community Exposure and other Related Learning Experience Activities.
(Activity)

Parent’s / Guardian’s Signature

Date:

Witness: NOTARY
PUBLIC

Doc. No. _______:

MAE DAYANNE M. SOLIVEN, RN, CRN, MSN Page No. _______:
Faculty In-charge Book No. _______:
Series of _______.

Noted:

PILAR V. DOMAGSANG, MAN, RN

Dean

SUBSCRIBED AND SWORN to before me this _____ day of _______________, _________ at Musuan, Maramag, Bukidnon, affiant
exhibiting to me his Community Tax Certificate/ identification card indicated below his name.

CMU-F-1-ACA-016 01 June 2015 Rev. 0