Republic of the Philippines

CAMARINES SUR POLYTECHNIC COLLEGES

Nabua, Camarines Sur

COLLEGE OF HEALTH CARE TECHNOLOGY

http://www.chctcspc.multiply.com

Nabua, Camarines Sur www.cspc.edu.ph

(054) 288-4424 loc 222 cspc.chct@gmail.com

CHCT nationalistic, and upon completion of the program demonstrate professional

Vision competencies.

The program
envisions
the CLINICAL DUTY AGREEMENT AND LIABILITY WAIVER
production
of highly Mr. & Mrs.______________________, a parent/guardian of Mr./Ms.
qualified ____________________, a student of Camarines Sur Polytechnic Colleges of CHCT
and globally Department hereby agree to the following RLE / Clinical Duty Condition:
competitive
graduates in 1. That I shall abide by all the rules and regulations, terms and conditions of the
the field of _______________________.
midwifery
and nursing. 2. That as a parent/guardian, I am allowing my son/daughter to stay in
_______________________ so as to curtail expenses during the clinical duty. State
inclusive dates __________________.
CHCT 3. That I shall renounce and waive any claim against ___________________ and be
Mission made answerable of any liability or inquiry which may be occasioned while my
son/daughter is in the custody/place of my relative where he/she is staying.
The CSPC
College of Health Signed this ______ day of ___________, 20__ at the office of the Dean HCT
Care Technology Department, Camarines Sur Polytechnic Colleges, Nabua, Camarines Sur,
through its ladder Philippines.
program is
committed to With our consent and approval:
provide quality
education that __________________________ _________________________
will harness the Name of Parents/Guardian Signature of Student
maximum Community tax No.__________ Community Tax No._________
potential of the Issued at__________________ Issued at__________________
learner, develop On_______________________ On_______________________
a midwife/nurse
who is
intelligent, _____________________________________
caring, MARIA LAARNI M. SALCEDO, RN, MAN, PHD
responsible, Dean, College of Health Care Technology
Community Tax No.__33878760____________
Issued at _Nabua, Camarines Sur___________
On__March 25, 2010_____________________

rasaño
 Republic of the Philippines
CAMARINES SUR POLYTECHNIC COLLEGES
Nabua, Camarines Sur

COLLEGE OF HEALTH CARE TECHNOLOGY

http://www.chctcspc.multiply.com

Nabua, Camarines Sur www.cspc.edu.ph

(054) 288-4424 loc 222 cspc.chct@gmail.com

Subscribed and
sworn before
me this
___________
day of
________,
20___ at
_____________
_, Philippines.

rasaño