WAIVER / UNDERTAKING

We, __________________ (student-trainee) and __________________ (parent/

guardian), hereby execute this Waiver/ Undertaking to hold the Polytechnic University of the
Philippines and the training institution free from any liability for any injury / illness / loss of life or
property that may be incurred/ sustained by the student-trainee in the course of his/ her on-thejob training / practicum with the raining provided that the same is not due to a willful criminal act
or gross negligence of the training institution or any of its representatives, officers or employees.
As the parent/ guardian of the student-trainee, I hold myself responsible for any
expenses that may be incurred as a result of the student`s illness, injury, death or loss or
property in the course of the student`s on-the-job training/ practicum, except as provided above.
I further undertake to be responsible for any breakage, loss of property, damage, death or injury
that may be caused by the student-trainee to any party while undergoing training.
We execute this Waiver/ Undertaking in accordance with our free will, realizing the
benefits that the student-trainee shall obtain from the said on-the-job training/ practicum.

_______________________
Printed Name and Signature of
Parent/Guardian

__________________________
Printed Name and Signature of
Student-Trainee

REPUBLIC OF THE PHILIPPINES)

CITY OF ____________ ______)
Subscribed and sworn to before me affiants exhibiting valid proofs of their identity as follows:
Name
__________________________
__________________________

ID No.
________________________
________________________

Issued at/ on
____ ________________
_______ _____________

They acknowledge to me that the foregoing Waiver/Undertaking was executed in

accordance with their own free will.

Doc No. __ ____;

Page No. ______;
Book No. ______;
Series of ____ __