Control Number: _____________

LYCEUM OF THE PHILIPPINES UNIVERSITY

[ X ] Manila [ ] Makati [ ] Cavite

PARENTAL/GUARDIAN CONSENT
OFF CAMPUS STUDENT ACTIVITIES

Note: This form must be duly notarized. Erasures/alterations are not allowed.
Name: Student number: Section:
Activity: Annual Student Leaders’ Congress
Destination: Balai Indang, Cavite Duration: __1__ nights __2____ days
Personnel-In-Charge: Dean Jayson M. Barlan
Tour Date/s: July 29-30, 2019
Tour Price: FREE (Budget c/o SAO and LYCESGO)
Tour Inclusions: Transportation, Meals, Training Materials, Accommodation
Organizing Unit/Dept.: SAO and LYCESGO

As one of the participants in this activity, I hereby acknowledge that:

1. I am fully aware of the rules and regulations of the University concerning student conduct and that I will not violate
said rules of any directive or instruction made by the person or persons in charge of said activity;
2. I will further assume the complete risk of any activity done in violation of any rule or directive or instruction;
3. I am aware that unless I submit this PARENTAL/GUARDIAN CONSENT, duly filled out, signed, and notarized, I will
not be allowed to join the tour;
4. In the event of any untoward incident that may arise in the course of the duration of the activity, in spite the best
efforts of the organizers to maintain the safety and security of the attendees, the cost of medical expenses related to
the incident shall be covered by the benefits of the Student Personal Accident Insurance which shall be facilitated by
LPU and/or the insurance group provided by the travel agent/tour service provider;
5. And I, Parent/Legal Guardian, understand the nature of the abovementioned activity and believe my son/daughter to
be capable, qualified, in good health, and in proper physical condition to participate in such activity.

By affixing my signature on this form, I hereby acknowledge and certify that I have carefully read and understood the terms and
conditions of the Data Privacy Policy of the Lyceum of the Philippines University (LPU). By providing personal information to
LPU, I am confirming that the data is true and correct. I understand that LPU reserves the right to revise any decision made on the
basis of the information I provided should the information be found to be untrue or incorrect. I likewise agree that any issue that
may arise in connection with the processing of my personal information will be settled amicably with LPU before resorting to
appropriate arbitration or court proceedings within the Philippine jurisdiction. Finally, I am providing my voluntary consent and
authorization to LPU and its duly authorized representatives to lawfully process my/my child’s data/information.

In witness, I have hereunto affixed my signature this _______ day of ___________ 20 ____ in _____________________.

__________________________________________ _____________________________________________
Signature over Printed Name, Student Signature over Printed Name, Parent/Guardian

Complete Address:
___________________________________________________
Contact Number: ____________________________ ___________________________________________________
___________________________________________________

Noted by: Endorsed by: Approved by:

______________________________ ______________________________ ______________________________

Name/Signature, Faculty Adviser Name/Signature, Chairperson/Head Name/Signature, Dean

SUBSCRIBED AND SWORN to me, in the Municipality of ____________, this ______th day of __________, 20_____
by, ____________________ with ID No. _____________ issued at _____________________ in the City of _____________.

NOTARY PUBLIC

Doc. No. _________;

Page No. _________;
Book No. _________;
Series of 20 _______.

Please attach a photocopy of the ID (valid government issued with photo and signature) of the Parent/Guardian. Submit this PARENTAL/GUARDIAN
CONSENT, attachment, and the Medical Certificate to the Travel Office/Tour Organizer.

The organizer reserves the right to adjust trip itinerary or traveling dates for valid reason/s.