Parental Waiver

OFFICE FOR STUDENT AFFAIRS

University of St. La Salle
Bacolod City


Type of Activity: Junior Philippine Institute of Accountants Socials Night Venue: Circle Inn Grand Ballroom
Inclusive Dates: January 25, 2014 Time Finished: 11:30PM
To: The Director of Student Affairs
I hereby willingly and voluntarily consent to the participation of my
son/daughter__________________________________________________________ to the aforementioned activity. I
have considered the benefits that my child/children will derive by participating in the overnight activity. I understand
that I will not hold any party responsible for any untoward incidents which may happen in the course or duration of the
activity as long as proper care and due diligence are observed to insure the safety and security of my son/daughter.

________________________________________ _________________
(Parent Name and Signature of Guardian/Parent) Date

Address: _________________________________

Contact Numbers: __________________________

STUDENTS CONTRACT
I affirm that all information contained herein are true and correct, that I will not hold the University of St. La Salle or any
instrumentality thereof responsible for any untoward incidents that may happen due to personal negligence,
irresponsible behavior, or lack of attention that will constitute a violation of prearranged instructions given to insure my
safety and security and therefore beyond the control of duly designated peer leader or faculty moderator. I also
understand that all rules and policies pertinent to school activities are applicable and in force.
CONFORME:
_____________________________ ____________________ ___________________
Printed Name Signature Course

Important reminders: Student/s without Parental Consent cannot attend the activity mentioned above.
For strict compliance.

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PARENTS COPY
Type of Activity: Junior Philippine Institute of Accountants Socials Night Venue: Circle Inn Grand Ballroom
Inclusive Dates: January 25, 2014 Time Finished: 11:30PM
Moderator in Charge: Mr. Ed Mark P. Rustico, CPA Contact Number: 09236721047