Form No.

UG-08

STATEMENT OF RESPONSIBILITIES
In connection with the admission and enrollment of __________________________________________________________________,
NAME OF THE STUDENT (Last Name, First Name and Middle Name)

The person named below is the designated Parent/Guardian On Record at De La Salle University:
De La Salle University Science and Technology Complex

___________________________________________________________________________________________________________
LAST NAME FIRST NAME MIDDLE NAME

Mailing Address: _____________________________________________________________________________________________

_____________________________________________________________________________________________

Relationship to Student: _____________________________ Email Address: _____________________________________

Telephone Number: _____________________________ Mobile Number: _____________________________________

As the Parent/Guardian, I understand and agree with the following:

RESPONSIBILITIES
1. The non-refundable fee of PhP10,000.00 will be credited to tuition and fees assessment upon enrollment for the term of the
academic year and in case of withdrawal of confirmation, it will be charged against the administrative and processing costs. (NOTE:
Not applicable to students who defer enrollment);

2. The Parent/Guardian On-Record must pay the tuition fee increase as decided by the DLSU-Multi Sectoral Committee, or the tuition
fee increase mandated by the government, if any, for the duration of our childs stay in the University;

3. The Parent/Guardian On-Record must abide by the rules and regulations governing our enrolment at De La Salle University, as
specifically stated in the Student Handbook and/or other University circulars/memoranda;

4. The Parent/Guardian On-Record must attend official activities of the DLSU PUSO (Parents of University Students Organization), the
parent organization acting as liaison between DLSU parents and the rest of the school community; and

5. The Parent/Guardian On-Record has equal access to the students official school records through the My.LaSalle Parent account.

6. The Parent/Guardian On-Record allows the student to undergo the Mandatory and Random Drug Testing initiated by DLSU and the
government pursuant to RA No.9165 and Sec. 1.20.3 of the Student Handbook

CONDITIONS (For Parent/Guardian On-record)

1. The Parent/Guardian On-Record shall be the addressee of all communications, if any, sent by De La Salle University.
Communications may be sent to any of the contact information provided herein, and that the same is active and valid until
superseded through a written notification by the Parent/Guardian On-Record;

2. The Parent/Guardian On-Record shall be the payee of all checks in connection with tuition refunds, if any;

3. The student named above may act as Parent/Guardian On-Record when of legal age, subject to the procedures for changing
Parent/Guardian On-Record;

4. A change of the Parent/Guardian On-Record requires the authority of the undersigned and the current Parent/Guardian On Record
through a notarized Affidavit of Change of Parent/Guardian On Record;

5. The administrative costs in connection with a change of the Parent/Guardian On-Record may be assessed by De La Salle
University;

_______________________________________ ____________________________________
SIGNATURE OF PARENT/GUARDIAN OVER PRINTED NAME SIGNATURE OF STUDENT OVER PRINTED NAME

_________________________________ __________________________________
DATE DATE

**Note: This form must be accomplished in duplicate.

2401 Taft Avenue, 1004 Manila, Philippines | Direct Line: (632) 523-4230 | Trunk Line: (632) 524-4611 loc. 166
admissions@dlsu.edu.ph | www.dlsu.edu.ph/admissions