Republic of the Philippines

CENTRAL LUZON STATE UNIVERSITY

Science City of Muñoz, Nueva Ecija

OFFICE OF THE VICE PRESIDENT FOR ACADEMIC AFFAIRS

LOCAL OFF-CAMPUS ACTIVITIES

PARENT’S/GUARDIAN’S CONSENT
______________
(Date)
Dear Parent/Guardian,

This is to inform you that your son/daughter _____________________________________________ who is

(Name)
Choose the most appropriate situation:

 enrolled in the subject _______________ (________________________________________________________)

(Cat. No.) (Descriptive Title)
 student from the _____________________________________________________________________________
(Name of College)
 member of the organization/council ______________________________________________________________
(Name of Student Organization/Student Council)

is encouraged to join the __________________________________________________________________________

(Name of Activity)
on _________________________ at ________________________________________________________________.
(Date) (Place)

Please be informed further that each student shall contribute _____________________________________

(Amount in Words)
(P________________) which shall be used to defray the following expenses: _______________, _______________,
(Amount in Pesos)
_____________, _____________, _____________ and _____________ (indicate the appropriate items).

The other pertinent information regarding the activity are:

Personel-in-charge: ____________________________________ Contact number: ____________________________
Objective/s of the activity: _________________________________________________________________________
______________________________________________________________ Number of participating students: _____
Vehicle to be used: ______________ Owner: _______________ Accommodation venue (if applicable): ___________
Security measures: ______________________________________________________________________________.

In case you are interested to clarify something regarding the activity, please contact
__________________________________ through the telephone/mobile number ___________________________.

Be assured that the safety of your son/daughter shall be our primary concern.

Very truly yours,

___________________________________
Name and Signature of Personnel-in-charge
-----------------------------------------------------------------------------------------------------------------------------------------------
To whom it may concern:

This is to certify that I have read the above letter and that I am allowing my son/daughter/ward
__________________________________ to join the ___________________________________________________,
(Name of Student) (Name of Activity)
which is scheduled to be on ______________________________ at ______________________________________.
(Date/s) (Destination/s and/or Venue/s)

I release and discharge the Central Luzon State University from any liability of whatever nature.

_______________________________________
Printed Name and Signature of Parent/Guardian
Please provide the following information:
Contact number: ___________________________________ E-mail address: ______________________________
Home/Mailing address: ____________________________________________________________________________

SUBSCRIBED AND SWORN to before me, this ______________________________, by ______________________ who exhibited to me (his/her)
competent proof of identification____________________________________ issued at ____________________________________________,
Philippines on _________________________________.

Notary Public
Doc. No. ______;
Page No. ______;
Book No. ______;
Series of ______. (Please accomplish in triplicate)
ACA.XXX.YYY.F.010 (Revision No. 1; September 22, 2017)