ERESERYE No.

78322

For Curricular and (o-Curricular

Act1v1t1es (students copy page I of 2)

UNIVERSITY OF SANTO TOMAS

ÜPQM, Manila

UST NATIONAL SERYICE TRAINING PROGRAM CWTS/LTS OFFICE

NAN[ Of ORGAHtlA TKJN

Dear Parents/Guardians :
Your son/daughter/ward has enrolled in the National Service Training Program of the University of Santo Tomas under the ill
component andas such is required to attend the NSTP Fie)dwork to be held on 02 February 2020 at Sitio Ma)an, Bamban, Tar)ac
To ensure the safety of your son/daughter/ward, please see attached NSTP CWTSILTS Emergency Plan Protocol and Venue Map of the
Fieldwork.

1. 1, Rona R. Repancol the Facilitator from the NSTP Department will be accompanying the students. You may contact him/her at
4061611 loe 8475 or 8S67 for further inquiries.
2. An ocular visit and coordination with the community leaders have done by the Facilitator.

Kindly fill-out the attached "Statement of Parental Consent'' and return the same to Rana B Benancn)
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of the UST NSTP CWTS)LTS OFFICE
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00 or befare
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Sincerely yours,

Noted:

fSIGNATU«C 0\/'Elt f'ltlftffCO NAMC O( HSrf' MODCltATO«)

x---------------------------------·---------------------------------------------·
STUDENT UNDERTAKING AND STATEMENT OF PARENTAL CONSENT
This copy to be retained by the faculty For Curricular and Co-Curncular
Act1v1t1es (students copy page I of 2)

Activity Tille: Literacy Training Service

Where: Sitio Malasa, Bamban, Tarlac 1 When: 02 Februory 2020
Nature of Activity: Fieldwork

College/Organization (Organizer): UST NATIONAL SERVICE TRAINING PROGRAM CWTS/LTS OFFICE

Person/Officer-in·Charge: Rona R. Repancol
Position: NSTP Facilitator
Mobile No.:0998128456 1 Tel. No.:34061611 local 8475 1 E· Mail:rrrepancol@ust.edu.ph

STUDENT UNDERTAKING AND STATEMENT OF PARENTAL CONSENT

FIRST NAME MIDDLE NAME LAST NAME 1STUDENT NO.

ADDRESS

MOBILE NO. 1 LANDUNE NO. \ E-MAIL

Name of person to be contacted in case of emergency:

Contact Nos.:
1, whose name appears above, hereby express my intention to join the above stated activity, organized
by the UST NATIONAL SERVICE TRAINING PROGRAM CWTS/LTS OFFICE

to be held on 02 Februory 2020

In connectlon with the above mentioned activity, 1 hereby warrant and represent that:

UST:S030-00.f030
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 [ RESERVE No. 711322

for Curuculu and Co·Currlíula,

Ac ll\ltlle'S. ,-.1ud"nt~ (Op)' P•Qt.' l. vf l 1

l. PARTICIPATION GUIDELINES UST NSTP CWTS/LTS

1. Fieldwork Attire: NSTP Shirt, long pants and FIELDWORK/ OFF.CAMPUS ACTIVITY
EMERGENCY PLAN PROTOCOL
rubber shoes.
2. No Medical Certificate and Sianed Parental Pro! Arvm Eballo, PhD
Consent, No trip. SIMBAHAYAN DIRECTOR
3. Show proper decorum.
4. Bring your food, drinks and medication (if Assoc. Prof. Jose Ricarte B Orlgene1
NSTP CWfS/LTS MODERATOR
applicable). Observe the Styrofoam Free jborigenes@uat.edu ph
Policy 0917-8280381 / 0942-0668881
S. Prepare at least Php. 300.00 for your
transportation fee. Name
6. Bring the materials your facilitator has FACILITATOR
rrrepancol@ust.edu. ph
instructed you for the fieldwork. 0998128-4568
7. No smoking.
8. Should there be a cancellation, you will be STEP 1: Any untoward inciden! durlng the field work or off-campus
notified by your Facilitator. activtty, the facilltator mus! bring the student to the neareat hospital
/ !he UST Health Service / nearest pollee station.
9. Please be advised that the provisions of the STEP 2: The facilltator immediately contacta the NSTP CWTS/LTS
Student Handbook shall be strictly observed Moderator to report about the sttuation.
during the fieldwork activity. STEP 3: The facilltator contacts the parents or guardian to inform
11. MAP (SEE SEPARATE PAPER) about the condltioo and whereabouta of the student.
STEP 4: The NSTP CWfS/LTS Moderator communicalet wilh the
Simbahayan Director and report the incident.
STEP 5: The NSTP CWTS/LTS Moderator c1osety monitors the
111. FIELDWORK DETAILS WILL BE facilltator of the development of the sttuation and report the
condttion to the Director from time to time.
COMMUNICATED BY YOUR FACILITATOR.
STEP &: The NSTP CWTS/LTS Moderator coordinatet wilh the
Please check your UST Cloud Campus UST Hospttal, ~ the student needs to be transferred.
Announcement Page. STEP 7: The facilttator submtts a written incident report to the
NSTP CWTS/LTS Offoce and addressed to the NSTP CWTS/LTS
Moderator. A copy will be fumished to the Simbahayan Director for
proper action.

X ------------------------------------------------------------------------------------------------------·
for Curricular and (o-Curricular
Act1\lt1e<, lstudents copy p,lg+: ~ of ~•

1. 1 take it as my responsiblllty to take the necessary precaution or care of avoiding or gettlng lnvolved in any incldent that would cause
slight, serlous or morul lnjury upon my person or results in the loss or dama.ge to my property and that of other person.

2. 1 also understand that I am not to engage in any behavior that could or may lead to any inciden! or could result to loss or damage to
property, lnjury to myself or other person(s).

3. 1 understand that it is my responsibility to fully ascertain, if necessary with the help of a medica! professional, my physical and menta.!
fitness to Join this activity.

4. 1 understand that I must be sufficiently healthy or free from any medica! condition that maybe exacerbated or aggravated by my
participation in such an activity. Should I be suffering from any medica! condition that maybe aggravated or exacerbated by such an
activity, 1 commit to immediately report such condltion in writing to the assigned faculty adviser. 1 have not been sick, injured , nor
confined to a hospital or suffered any medica! condltion requiring medical attention since my last mediul examinatlon conducted on
(mm) ___ (dd) _ _ (yy) _ _ and as evidence by the attached Medica! Examination Report.

5. 1 have properly informed my parents or the person(s) exercising parental authority over my person concerning the nature of the activlty
which I am joining and likewise secured their advice on the measures which I am to undertake for my personal safety and security.
Furthermore, 1 have secured their consent forme to join such an activity as evldenced by the signature appearing hereln.

6. 1 am fully convinced that the University and the faculty adviser(s) and organizer(s) of this particular activi ty have exercised suffici ent
diligence and care in the preparation and implementatlon of this activity.

Attention: For the student, parent or person exerclslng parental authority over the student concerned, affixing your
signature herein shall mean that you conform. agree to the conditions stated above and consent to the participation of
your son/daughter/ward in the said activity and. further hold the university free and harmless from any liability arising
from the said activity.

SIGNATURE OF STUDENT SIGNATURE OF PARENT/GUARDlAN

STUDENT'S NAME IN PRINT PARENT/GUARDIAN'S NAME IN PRINT

UST S030· 00-fO30

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