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Republic of the Philppines

BULACAN STATE UNIVERSITY


COLLEGE OF CRIMINAL JUSTICE EDUCATION
City of Malolos, Bulacan

INTERNSHIP WAIVER

I, KERNELL SONNY J. SALAZAR, of legal age, residing at 418 Narra St., Mahabang Parang, Santa Maria,
Bulacan, and a 4th year student of Bulacan State University, College of Criminal Justice Education, by this
document hereby declare:

1) That as part of our curriculum, I have to undergo Student Internship consisting of 300 hours
outside the confines of the University;

2) That I have chosen Regional Trial Court, Branch 14, City of Malolos, Bulacan as the
appropriate place where to render my Internship;

3) That I understand and agree to abide by the policies and standards of the organization for
which I will be working and that may be implemented by my supervisor and our student
internship coordinator in relation to my training;

4) That the University does not provide health insurance (except student health insurance) and
that I will cover medical services that might be necessary due to accidents, illnesses or
injuries I may face while participating in this internship;

5) That I acknowledge as a student of Bulacan State University I also remain subject to the
University’s disciplinary processes for my conduct on internships organized or facilitated by
the University.

6) That I assume full and sole responsibility for all damages incurred or caused by me arising
out of and in the course of my aforesaid training in the said place;

7) Furthermore, I renounce and waive all claims against Bulacan State University and for any
injury that I may sustain or for any loss that I may suffer, personal or pecuniary, in the
performance of my duties or functions as intern due to my negligence.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 12th day of February, 2018, here
at City of Malolos, Bulacan.

___________________________________________
SIGNATURE OVER PRINTED NAME
CONFIRMATION

That I, SANTIAGO G. SALAZAR (father/mother/guardian), of legal age, Filipino and a resident of 418
Narra St., Mahabang Parang, Santa Maria, Bulacan, after being duly sworn in accordance to the law, hereby
agree and state:

That I confirmed the above waiver appearing in this document.

___________________________________________
SIGNATURE OVER PRINTED NAME

SUBSCRIBED and SWORN to me before this 12th day of December 2018, affiant exhibiting his/her
Student ID bearing no. 20014-11128 issued at Bulacan State University, SY 2018-2019 as competent proof of
his/her identity.

___________________________________________
ADMINISTERING OFFICER

DOC. NO.
PAGE NO.
BOOK NO.
SERIES OF ______

BulSU-OP-OSI-16F3
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