B i c o l U n i v e r s i t y Legazpi City, Philippines

Parents’ /Guardians’ Permit Form

_____ semester, SY ______________

PLEASE TAKE NOTE CAREFULLY

1. Please fill up this form in BLOCK LETTERS.
2. ALL sections MUST BE COMPLETED when applicable.
3. Permit should be duly NOTARIZED for Educational Tour/Field Trip purposes and when participant is a minor.

TO WHOM THIS MAY CONCERN

This certifies that ____________________________________________, a ________________
(Course and Year)

of the College of ____________________________________ with Student No. ___________________

has the permission of his/her undersigned parent(s)/guardian(s) to participate and/or attend in the
______________________________________________________ on ________________, 20 _____
in _______________________.

This certifies further that risk assessment plans and necessary safety and precautionary
measures have been instituted.

Further, that the following faculty members shall accompany him/her in the travel.

1. ___________________________________ _____________________________
Faculty Name (Please print) Faculty Signature

2. ___________________________________ _____________________________
Faculty Name (Please print) Faculty Signature

3. ___________________________________ _____________________________
Faculty Name (Please print) Faculty Signature

4. ___________________________________ _____________________________
Faculty Name (Please print) Faculty Signature

Note: If the student is a minor, both parents MUST sign the permission form.
I/We have honestly and accurately completed all parts of the Parents’/Guardian’s
Permit Form to the best of my/our ability.

_________________________________ _________________________________
Parent/Guardian Signature #1 Date Parent/Guardian Signature #2 Date

_________________________________ _________________________________
Parent/Guardian Name (please print) Parent/Guardian Name (please print)

_________________________________ _________________________________
Complete Address Complete Address
_________________________________ _________________________________
Contact Numbers Contact Numbers

JURAT

On ________, of 20 ___, before me personally appeared, ______________________________

and ___________________________________ to me known to be the individual, or individuals
described in and who executed the within and foregoing instrument, and acknowledged that
he/she/they signed their free and voluntary act and deed, for the uses and purposes therein
mentioned.

Given under my hand and official seal this ______ day of _________________, 20 ____.

Notary Signature: __________________________ Affix seal

here
Notary Printed Name : ____________________________

My commission expires: ___________________________

Office of Student Services

Student Activities Section
BU OSS S A S
BU-F-OSS-34
Effectivity: September 13, 2012 Revision No. 1 P. 1 of 1