Parents’/Guardian’s Certification of Waiver/Permission

This is to certify that I am allowing my son/daughter/ward

__________________________________ to go on the Work Immersion Program for a
minimum of eighty hours (80 hours) starting on ___________________________ until
__________________________ at (name of company) _________________________________
in partial fulfillment of the requirements for the Senior High School.

I understand that he/she abides by the rules and regulations that may be imposed by the
Supervisor/Staff-in-Charge for his welfare and safety.

I understand that every precaution was taken to ensure the safety of my

son/daughter/ward and that I will not hold the school, the company, and/or the representative/s,
liable for any unforeseen and untoward incident that might happen to my son/daughter/ward
during the duration of the practicum.

Name: ______________________________________________
Relationship to Student: ________________________________
Name of Student: _____________________________________
Address: ____________________________________________
Contact No.: _________________________________________

Signature: ___________________________________________
Date: _______________________________________________