COLLEGE OF NURSING

______________________________________________________________________________________
WAIVER AND RELEASE FOR RELATED LEARNING EXPERIENCE
(Limited Face-to-Face RLE)

_______AY : 1ST Sem ; 2nd Sem

We/I, ___________________________________have given ________________________permission to

attend the limited Face-to-Face Related Learning Experience in Skills demonstration and Return demonstration,
simulated community health nursing and hospital duty as stipulated in the Joint Memorandum Circular # 2021-001
and which is a part of the curriculum as per CHED memorandum # 15 series of 2017. We are aware of the risks that
our son/daughter may be exposed to during these Related Learning activities. Just the same, we allow him/her
without any reservation to participate in these Related Learning activities for the duration of his/her course. While
he is participating in the said learning activities, we hereby voluntarily and expressly waive any or all actions,
claims, or demands against University of the Cordilleras, its trustees, officers, teachers and/or employees should our
son/daughter suffer any injury or damages which may happened beyond the control of the faculty; and we hold
harmless the said University of the Cordilleras, its trustees, officers, teachers, and/or employees from any such
action, claim or demand.

Similarly, I, _____________________________________________, hereby voluntarily and expressly

waive any or all actions, claims or demands against University of the Cordilleras, its trustees, officers, teachers,
and/or employees should I suffer any injury or damages while I am participating in the said Related Learning
activities: and I hold harmless the said University of the Cordilleras, its trustees, officers, teachers and/or employees
from any such action, claim or demand, provided however, that utmost care, attention and precautions are
undertaken and/or exercised by those concerned.

I shall observe diligence to ensure myself and well-being.

I shall comply with rules and regulations set by the University and the organizing committee.

Signed this _____day of _________________________.

________________________________ _____________________________________
Name of Student Name of Parent/Guardian
(Signature over Printed Name) (Signature over Printed Name)
Contact Number: _______________________
Relationship: ____________________________

__________________________
Clinical Instructor

___________ ______________________________________________________
Program Chair on Classroom Instruction and Research

_______________________________________________ __________________________________________________________
Program Chair on Hospital Nursing Practice Program Chair on Community Health Practice,
Extension and Outreach Program

Noted by:

___________________________
Academic Dean

_________________________________________________________________________________________________________________________________
UC-CON-FORM-221
May 2021 Rev. 00 Control No. _______________