Republic of the Philippines

Ilu guna $tate lBotptecbrrir @uitrer$ity

Province of Laguna
WAIVER
Date;

To whom it may concern:

As the parent/guardian of
(Nome of Student)
Depa rtment/U nit SponsorinB Activity:
Nature of Activity
Date of Activity
Place of Activity
Time of Activity
Faculty/Adviserlstaff-in-Cha
Together with my child, I know that Laguna State Polytechnic University and its officers, faculty, and staffs are
expected to exercise the legal diligence required for the safety and well-being of my child for the duration and the place,
date and time of the activity as stated.
This legal diligence would include oral or written instructions whether given before or during the activity, that if
followed, would ensure the safety of my child.
lf my child disregards or fails to follow those instructions or should act on hislher own, I together with my child,
shall have no claims against the school, its officers, faculty, adviser, staff-in-charge should any damage be caused or liability
be incurred to property or person.
Respectfully yours,
Contact number:
Signsture 1ver Pilnted Name
of Poreot/Guardion
Contact number:
Sigt)otur" over Printed Nqne
ol Student
LSPU.OSAS.SF.OlO Rev.0 10 August 2016

Student Copy
Republic of the Philippines
Ilnguna Stste lFo lptecltni c 0Hni[r erriry
Province of Laguna
WAIVER
Date:
To whom it may concern:
As the parent/guardian of
{Name of Student)
Department/Unit Sponsoring Activity:
Nature of Activity
Date of Activity
Place of Activity
Time of Activity
Facu lty/Adviser/Staff-in -Cha rge:

Together with my child, I know that Laguna State Polytechnic University and its officers, faculty, and staffs are
expected to exercise the legal diligence required for the safety and well-being of my child for the duration and the place,
date and time of the activity as stated.
This legal diligence would include oral or wrifien instructions whether given before or during the activity, that if
followed, would ensure the safety of my child. . '
If my child disregards or fails to follow those instructions or should act on hislher own, I together with my child,
shall have no claims againstthe school, its officers, faculty, adviser, staff-in-charge should any damage be caused or liability
be incurred to property or person.
' Respectfutly yours , ,

Contact number:
Signoture over Pritlted Nome
of Parent/Guordian

Contact number:
Sign0ture over Printed None
of Student
LSPU.OSAS-5F-O1O Rev.0 10 August 2016