PARENT’S WAIVER FOR PRACTICUM IN PSYCHOLOGY

Date ___________________

To whom it may concern:

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

to do practicum work at________________________________________________________,
one of the practicum sites approved by the Psychology Department starting on the First
Semester AY 20___ - 20___.

It is understood that he/she will abide by the rules and regulations set by the practicum
faculty coordinator, who is tasked with close monitoring of the intern’s progress.

While I have been assured that previous intern’s assigned to various sites have safely
completed their assigned tasks, I fully agree towaive any responsibility on the part of St.
Dominic College of Asia and the psychology department’s faculty coordinator, in case of any
untoward incident that may happen to my son/daughter in the course of fulfilling the
requirements for practicum.

___________________________________
Student’s Signature over Printed Name/Date

__________________________________
Parent’s Signature over Printed Name/Date

Ms. Kimberly Joanna Dayrit, RPm

Faculty Coordinator’s Signature/Date

Dr. Philip C. Cuizon

Program Head, Psychology Signature/Date

Noted by:

Dr. Mary Nellie T. Roa

Dean, School of Arts, Science and Education