POLYTECHNIC UNIVERSITY OF THE PHILIPPINES

College of Engineering
Computer Engineering Department
NDC Campus, Sta. Mesa, Manila
Tel. No. 713-59-68

PARENTAL CONSENT AND WAIVER FORM

I, __________________________, grant permission for my son/daughter, _______________________, to

participate in the Computer Engineering Batch 2011 Educational Field Trip entitled: “Get IT Loud: Leading The Way
To Maintain One's Environment, Learning The Way To Outreach One’s Potential Through Engineering
Technology” which requires transportation to a location away from the university site. This activity will take place
under the guidance and direction of the Faculty and Batch 2011 Officers of the Computer Engineering Department,
College of Engineering of the Polytechnic University of the Philippines.

A brief description of the tour follows:

Location of event: Baguio City, Philippines

Date and estimated time of arrival/departure:
Arrival: March 6, 2011, 2:00 PM
Return: March 10, 2011, 5:00 PM
Mode of transportation: Bus Line Company Service (Victory Liner, Inc.)
Board and Lodging: Teacher’s Camp

I, as parent and/or legal guardian, remain legally responsible for any personal actions taken by the above named
participant.

I agree on behalf of myself, my child named herein, or our heirs, successors and assigns, to hold harmless and
defend Polytechnic University of the Philippines , its officers, directors and agents, employees, faculty, or
representatives associated with the event, from any and all actions, claims, demands, damages, costs, expenses
and all consequential damage arising from or in connection with my child attending the event or in connection
with any illness or injury or cost of medical treatment in connection therewith.

In signing the Parental Consent and Waiver, I am not relying on any oral or written representation or statements
made by the university and , its officers, directors and agents, employees, faculty, or representatives associated
with the event, to induce me to permit my student to take the trip, other than those set out in this Consent and
Waiver.

I am 18 years of age or more and have read and understand the terms of this consent and waiver, and recognize
that it is binding upon me, my heirs, executors and administrators.

_______________________________ __________________________
Parent/Guardian over Printed Name Date

Home Address: ____________________

Contact No(s): ____________________