WAIVER

STATEMENT

That I, ____________________________________________, ___________ years old,

( Complete Name )

( Age )

male/female, residing at ________________________________________________________

( Home Address )

and a parent/guardian of Mr./Ms. _________________________________________________

( Name of son/daughter/ward )

a 4th year Medical Technology student of DMC College Foundation, Inc. of the Academic Year
2015 2016, has been made aware of the rules and regulations governing the Medical
Technology Pre/Internship Training Program, as stated in the Medical Technology Internship
Training Program Manual, which includes the Pre/Internship Requirements, General Rules of
Conduct of an Intern, Appearance and Uniform, Attendance and Punctuality, Incidence
Requiring Disciplinary Action, Intimate Relationships, Grading System, Extension Duty,
Comprehensive Written Examination, and Graduation Requirements.
With full understanding of the above policies, I take responsibility for the untoward
consequences of my sons/daughters/wards actions and hereby hold free, the school and its
personnel, from any liability that may arise, monetary or otherwise for any all acts of omission
that cause damage of prejudice to any person during my sons/daughters/wards period of
pre/internship with the different affiliation centers during the First and Second Semesters of
School Year 2015 2016.
Finally, the undersigned hereby voluntarily assumes all risks of accidents or damages to
son/daughter/ward while in transit and/or travel to and from the assigned hospitals and hereby
releases and discharges the school, Dipolog Medical Center College Foundation, and its
representatives from all claims, liabilities or demands of any kind for or on account of any
personal injury or damaged sustained.
__________________________________
Signature over Printed Name of Parent/Guardian

__________________________________
Telephone/Mobile Phone Number

REPUBLIC OF THE PHILIPPINES )

CITY OF ____________________ ) S.S.
/- - - - - - - - - - - - - - --- - - - - - - - - - X

ACKNOWLEDGMENT
SUBSCRIBED AND SWORN before me this ____________________
in
______________________ Philippines . Affiant personally appeared before me and exhibited to
me his/her Community Tax Certificate No. _____________________ issued on
_______________________________ at ____________________________________.

_____________________________
Page No. _________
Doc. No. _________

Book No. _________

Series No. _________