(Form 4)

WAIVER

The College of ____________ of (Name of School), (City or District), has requested this waiver
in connection with its On-The-Job Training (OJT) Program offered this __ Semester of SY
_____ - _____ and which is accepted and confirmed. The student-trainee,

Complete Name, Course and Year

together with his / her parents or judicially appointed guardian acknowledge that the permission
granted to him is made subject to the condition, which he / she hereby accepts and agrees to, that
the university will not assume any responsibility whatsoever for any injury or accident which
may happen to him within or outside the premises of the project area during the period of said
program. It is understood that there is no employer-employee relationship between the
university and the student-participant.

This waiver will be in effect for the duration of ________________ to ________________ (the
duration of this Program).

Done this _____ day of ________________ (Year), in the (City or District).

_______________________________ __________________________________
Signature of OJT Participant Signature over Printed Name of Parent or
Judicially Appointed Guardian

Witnessed:

_______________________________
_________________________ Company/Agency/Bureau Representative
Dean, College of __________

___________________________________
Name of Company/Agency/Bureau