Republic of the Philippines

Laguna State Polytechnic University

Province of Laguna

WAIVER
DR. MARIO R. BRIONES
University President
LSPU-System

Sir:
I, ______________________________________________, of legal age, single/married, Filipino citizen, and a
resident of _____________________________________, hereby depose and say:

1. That I am the mother/father/guardian (please underline) of ______________________ enrolled at Laguna

State Polytechnic University;
2. That I hereby give my consent to my son/daughter/ward ________________________ to attend and
participate all University activities and programs including: Off-Campus (Seminars and Conferences outside the
University, On the Job Training, Tree Planting, Community Immersion, Extension and Outreach Projects, Academic
Activities, Local, Regional and National Competitions and Educational Tour) and In-Campus Activities within the
academic year 2019-2020.
3. That I hereby waive any claim of whatever nature against the Laguna State Polytechnic University and
release and forever discharge the institution, as I execute this affidavit, for myself, our heirs and assigns, from any
and all manner of action(s), suits, claims, damages and/or demands whatever which may I have against the said
institution for any untoward incident that may come beyond control;
4. That I finally declare that I have read and understood this document which is hereby given and made
willingly and voluntarily and with full knowledge of my rights under the law.

IN WITNESS WHEREOF, I have hereunto affixed my signature this _____ day of ____________ , 2019 at
________________, Philippines.

___________________________________
Name & Signature of Parent/Guardian
Identification Card & No.: ___________________
Issued on: ________________________________
Issued at: ________________________________
Date: ________________________________
____________________________________
Name & Signature of Student
Identification Card & No.:______________________
Issued on: __________________________________
Issued at: __________________________________
Date:__________________________________

Subscribed and sworn to before me this ______, day of _______, 2019 in ________________________,
Laguna. Affiant exhibited to me his/her ______________________________________.
(any valid ID of parent/guardian)

Doc. No.: _________

Page No: _________
Book No.:_________
Series of__________

LSPU-OSAS-SF-P08 Rev. 1 10 August 2016