WAIVER AND DECLARATION

KNOWN ALL MEN BY THESE PRESENTS:

I, JOHANNA LIZ BAJADA, of legal age, Filipino, single, and a resident

of Sto. Domingo St. Jaro, Iloilo City, Philippines, by these presents, hereby
states and declare that:

I am an incoming 4th year student intern of Bachelor in Medical

Laboratory Science, College of Nursing and Allied Health Sciences, Central
Philippine University (CPU), Lopez Jaena Street, Jaro, Iloilo City, Philippines.

I am aware and agree to abide with the policies of the Internship

program of the CPU Medical Laboratory Science Department and its affiliated
training laboratory for the AY 2016-2017.

I realize the risks connected with the aforesaid affiliation but I have
voluntarily applied to participate because it is a part of the curriculum and I
believe that the experience I will derive from the program will surely enhance
my understanding of my chosen course; moreover, it will be an essential part
of my educational training.

I declare under oath that I am psychologically, emotionally, and

physically fit to travel and participate in the said Internship program.

I shall not hold CPU or any of its trustees, officers, teachers, clinical
instructors, or representatives, criminally and/or civilly liable or responsible,
for my act that is contrary to laws and morals, or for any injury, damage, or
loss, that I may suffer in connection with the said training program, or for any
accidents that may arise by virtue of my own fault/negligence/force
majeure/act of God/fortuitous event beyond the control of CPU and its
trustees, officers, teachers, clinical instructors, or representatives, in
connection with the said training.

I shall take a comprehensive examination composed of eight subjects at

the end of the internship training and I commit to pass the examination by
having a general average of at least 75%.

I am aware that passing the comprehensive examination is a

requirement to become eligible for graduation.

I attest to the truth of foregoing facts.

 IN WITNESS HEREOF, I have hereunto affixed my signature this
___________, at Iloilo City, Philippines.

____________________________
JOHANNA LIZ BAJADA

Signed in the presence of

____________________________ and ____________________________

REPUBLIC OF THE PHILIPPINES)

CITY OF ILOILO ) S.S.
x___________________________x

BEFORE ME, on this ____________, at Iloilo City, Philippines,

personally appeared JOHANNA LIZ BAJADA, known to me to be the same
person who executed and signed in my presence, the foregoing Waiver and
Declaration, which consists of two (2) pages, including this page where the
acknowledgement is written, duly signed by her and her instrumental
witnesses, on each page hereof, and she acknowledge, to meet the same is
her free and voluntary act and deed.

JOHANNA LIZ BAJADA presented to me her

_____________________________, as competent evidence of identity under
2004 Rules on Notarial Practice as amended.

WITNESS MY HAND AND SEAL.

Doc. No. ______;

Page No.______;
Book No.______;
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