Form

STUDENT ACTIVITIES AND LEADERSHIP DEVELOPMENT

Office of Student Affairs, Xavier University Ateneo de Cagayan
Rm 204, 2/F Magis Student Complex (Tel) 858-3116 local 3330

A12 (2012)

PLEASE ENCODE
SACDEV Copy
Organizations
Copy

APPLICATION FOR OFF-CAMPUS ACTIVITY

(Please accomplish 2 copies. Electronic copy available at xusacdev@yahoogroups.com)

Name of Organization:

Name of Activity:

School of Business and Management Student Council

(Please type here.)

Inclusive Date(s) of Activity:

Venue/ Destination:

(Please type here.)

(Please type here.)

IMPLEMENTING GUIDELINES FOR OFF-CAMPUS ACTIVITY

1.

2.
3.
4.
5.
6.
7.

Accomplish and submit this APPLICATION FOR OFF-CAMPUS ACTIVITY (Form A12) to the Student Activities and
Leadership Development (Office of Student Affairs) at least 3 days before the activity. Please see Part V, Section C of
the Student Organization Manual for specific guidelines. Please encode. Download electronic copy through
xusacdev@yahoogroups.com.
Photocopy STUDENT TRAVEL AGREMENT (Form A12.1) and distribute to student participants. Ask students to accomplish
and submit accomplished forms by the deadline set by the organization.
Give copies of the ACCOMPANYING SCHOOL OFFICIAL TRAVEL AGREEMENT (Form A12.2) to the organizations
moderator. Ask moderator to accomplish and submit one copy of accomplished form to the organization. The other
copy is for the moderator.
Attach accomplished students forms (Form A12.1) and accomplished school officials form (Form A12.2) to this form.
All students going to an off-campus activity must be accompanied by their organization moderator or his/ her duly
appointed representative. Representative must also be a full-time faculty/ staff member of the University.
Only students who have submitted accomplished Form A12.1 shall be listed below and be allowed to participate in the
off-campus activity.
Any change made in the established schedule/ itinerary of the off-campus activity must be immediately communicated
to SACDEV-OSA.

COMPLETE LIST OF STUDENTS ALLOWED TO PARTICIPATE IN THE OFF-CAMPUS ACTIVITY

Full Name of Student
(Sample) De la Cruz, Juan Jr

Course and
Year
BS Bio 3

Students Mobile
Number
09178526256

Parent/ Guardians Name

Atty Juan de la Cruz

Parents Guardians
Mobile Number
09225689745

AGREEMENT:
We, cognizant of the risks and benefits entailed by our activity take upon us the responsibility of ensuring the safety of
everyone involved in our off-campus activity.
______________________________
Name and Signature of Project Head

DEOANALIN MAY L CASTILLO

Name and Signature of Organization President

I hereby agree to accompany the above-mentioned students in their off-campus activity. As moderator/ duly designated
representative of the University, I assume full responsibility for the proceedings of the activity and for whatever actions and
consequences that may arise from it.
MR LEO ARRABACA III
Name and Signature of Moderator
CERTIFICATION:
This is to certify that the aforementioned organization has successfully complied with all the requirements set for the
aforementioned off-campus activity.
MR IVANELL R SUBRABAS
Student Activities and Leadership Development Head

MS IRENE GRACE A GUITARTE

Director of Student Affairs

Form

STUDENT ACTIVITIES AND LEADERSHIP DEVELOPMENT

Office of Student Affairs, Xavier University Ateneo de Cagayan
Rm 204, 2/F Magis Student Complex (Tel) 858-3116 local 3330

A12 (2012)

PLEASE ENCODE

APPLICATION FOR OFF-CAMPUS ACTIVITY

(Please accomplish 2 copies. Electronic copy available at xusacdev@yahoogroups.com)

Name of Organization:

Name of Activity:

(Please type here.)

(Please type here.)

Inclusive Date(s) of Activity:

Venue/ Destination:

(Please type here.)

(Please type here.)

COMPLETE LIST OF STUDENTS ALLOWED TO PARTICIPATE IN THE OFF-CAMPUS ACTIVITY

Continuation

Page: ______________

Full Name of Student

(Sample) De la Cruz, Juan Jr

Course and
Year
BS Bio 3

Students Mobile
Number
09178526256

Parent/ Guardians Name

Atty Juan de la Cruz

Parents Guardians
Mobile Number
09225689745

CERTIFICATION:
This is to certify that the aforementioned organization has successfully complied with all the requirements set for the
aforementioned off-campus activity.
MR IVANELL R SUBRABAS
Student Activities and Leadership Development Head

MS IRENE GRACE A GUITARTE

Director of Student Affairs