UNIVERSITY OF SANTO TOMAS Community & Public Health (CPH) Fieldwork for 4th Year (Interns) B.S.

Medical Technology Students Second Semester, AY 2011-2012 Fieldwork/Community Exposure Waiver and Permission Form
This is to certify that I am permitting my son/daughter, _______________________________________ of 4 ___ MT, assigned at the _________________ Health Center, District ___ of the City of Manila, to undergo Fieldwork/Community Exposure for their “Community and Public Health” course that is in partial fulfillment for the degree of Bachelor of Science in Medical Technology. My son/daughter understands that he/she should strictly observe the institution’s (Manila Health Department/respective Manila Health Centers/Unit Barangays) rules on security and confidentiality of information and other regulations that may be implemented by his/her Faculty Field Preceptors or Health Department Staff for his/her welfare. I hereby agree to wave any responsibility on the part of the University of Santo Tomas in relation to any untoward incident which may happen to my son/daughter during the duration of the Field deployment for Public Health.

Father:

_________________________ Signature over printed name Mother:

_________________________ Signature over printed name Guardian:

_________________________ Signature over printed name

Noted by:

__________________________ Faculty Field Preceptor

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