PARENTAL CONSENT

I,_________________________________, residing at ________________________________

father/mother/guardian of ________________________________________a 4th year student of
Bulacan State University, College of ___________________________, by this document hereby
declare:

1) That as part of the BSU curriculum, my son/daughter have to undergo Student internship
consisting of ___ hours outside of the University;

2) That I, as the ___________, agree that my son/daughter will undergo internship for ___
hours;

3) That my son/daughter has chosen _______________________________________ as the

appropriate place where to render his/her internship;

4) That I understand and agree that my son/daughter have to abide by the policies and
standards of the organization for which he/she will be working and that may be
implemented by his/her supervisor and his/her internship coordinator in relation to his/her
training;

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

6) That I acknowledge that my son/daughter, as a student of Bulacan State University, also

remain subject to the University’s disciplinary processes for his/her conduct on
internships organized or facilitated by the university;

7) That I assume full and sole responsibility for all damages incurred or caused by my
son/daughter arising out of and in the course of his/her aforesaid training in the said
place;

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of ___, 2019, here
at City of San Jose Del Monte, Bulacan.

_________________________________
SIGNATURE OVER PRINTED NAME
 CONFIRMATION

That I, _________________________________ (father/mother/guardian), of legal age,

Filipino and a resident of _______________________________________________________

_____________________________________, after being duly sworn in accordance to the law,

herby agree and state:

That I confirmed the above parental consent appearing in this document.

_________________________________
SIGNATURE OVER PRINTED NAME

SUBSCRIBED and SWORN to me before this ___ day of __________ 2019, affiant
exhibiting his/her Student ID bearing no. ___________________ issued at Bulacan State
University, SY 2019-2020 as competent proof of his/her identity.

_________________________________
ADMINISTERING OFFICER

DOC. NO.

PAGE NO.

BOOK NO.

SERIES OF _____