University of Saint Louis Document No.

: FM-SAS-054
Tuguegarao City
Revision No.: 00
OFFICE OF STUDENT AFFAIRS AND SERVICES
Effectivity Date:
PARENTS’ WAIVER FOR FACE-TO-FACE CLASSES

WE,

Complete Name of Father/Guardian Complete Name of Mother/ Guardian

who are legal parents / guardian of

Complete Name of the Student

with residence at

Street Barangay Town/ City Province ZIP Code

do hereby, certify that we give full consent for him/her to join in the
LIMITED FACE-TO-FACE CLASSES

Name of the Activity

which will be held at on

the USL Classrooms, Laboratories and Grounds between February 23-May 30,
2022

Venue of the Activity Date of the Activity

under the following conditions:

1. WE HAVE REMINDED OUR CHILD/ WARD TO FOLLOW THE IATF PROTOCOLS AND THE USL COVID-19
PREVENTION & CONTROL POLICY AS A PROACTIVE MEASURE TOWARDS AVOIDANCE OF PROLONGED
EXPOSURE TO OTHER USL STAKEHOLDERS, AND OF ANY UNTOWARD INCIDENT;
2. Our child/ward will be with his/her teacher/instructor following the 4-10 cycle (4-day limited classes
and 10-day quarantine) based on the CHED and DOH memorandum orders;
3. The teacher/instructor will see to the safety, behavior and physical upkeep of our child/ward as far as
humanly possible following the IATF, CHED-DOH, LGU and USL protocols.
4. Considering the above conditions and the benefits that our child/ward will gain from his/her
participation in the aforementioned activity, and realizing that every precaution will be undertaken by
the teacher/instructor, we the undersigned parents/guardian of the above-named student hereby give
him/her our consent to attend the said activity.
5. That we assume responsibility and thereby waiving any responsibility for USL or any of its staff for any
incident that may happen on the occasion of the said activity beyond the control of the
teacher/instructor.

I/we certify further that below is/are my/our TRUE AND CORRECT SIGNATURE/S.

Parent’s/Guardian’s Signature Over Printed Name Parent’s/Guardian’s Signature Over Printed Name
Contact #: __________________________ Contact #: ____________________________

Address:
Date Accomplished: