PALAWAN STATE UNIVERSITY- QUEZON CAMPUS

Brgy. Alfonso XIII, Quezon, Palawan, Philippines

WAIVER

The Palawan State University – Quezon Campus, has requested this waiver in connection with
Limited face to face program offered this Second Semester of School Year 2021-2022 which is
accepted and confirmed.

I/WE, __________________________________ and _________________________ as parent

or legal guardian of __________________________________________ , a
_____________________________ and a resident of ___________________, hereby give our
full consent and approval for our son/daughter to attend the limited face to face classes which
will commence on ______________ .

This is to certify that the undersigned student together with his/her parents or 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, accident or covid transmission which may happen to him within or outside the
premises of PSU Quezon Campus.

This waiver will be in effect for the duration of the limited face to face classes from March 2022
to May 2022.

Done this ______ day of ___________ 2022, in the Municipality of Quezon, Palawan,
Philippines.

______________________________ ____________________________
Signature of Student Signature over Printed Name of
Parent / Guardian

______________________________ ____________________________
Contact Number Contact Number

Witnessed:

____________________________
Signature over Printed Name of
Program Head

Prof. DANTE V. ARIÑEZ

Campus Director