WAIVER/UNDERTAKING

We, (student) 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 in the course of his/ her activity
with the training institution provided that the same is not due to any 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, I hold myself responsible for any expenses that may be
incurred as a result of the students illness, injury, death or loss or property in the course of the
students activity, 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 to any
party while undergoing training.

We execute this Waiver/ Undertaking in accordance with our free will, realizing the benefits that
the student shall obtain from the said activity.

(Printed Name and Signature of (Printed Name and Signature of

Student) Parent/ Guardian)

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 acknowledged to me that the foregoing Waiver/ Undertaking was executed in

accordance with their own free will.

NOTARY PUBLIC

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