Republic of the Philippines

NUEVA VIZCAYA STATE UNIVERSITY

Bambang, Nueva Vizcaya

PARENTAL/GARDIAN CONSENT FORM AND LIABILITY WAIVER

(In compliance with CHED Memorandum Order No. 63, Series of 2017)
I, , grant permission to my child,
(Print legibly Parent/Guardian’s Name)
, to participate / attend / join,
(Print legibly Child Student’s Name)

The following ( ) curricular ( ) non-curricular activity:

I, as parent and/or legal guardian, I remain legally responsible for any personal actions
taken by the above named child/student.

I agree on behalf of myself, my child named herein, our heirs, successors and assigns, to
hold harmless and defend the Nueva Vizcaya State University, its officials/officers, directors
and agents, employees, faculty, or representatives associated with the event, from any and all
actions, claims, demands, damages, cost, expenses and all consequential damage arising from
or in connection with my child attending the event or in connection with any illness or injury
or cost of medical treatment in connection therewith.

In signing the Parental/Guardian Consent Form and Liability Waiver, I am not relying on
any oral or written representation or statements made by the University and its officers,
directors and agents, employees, faculty, or representatives associated with the event, to
induce me to permit my child/student to trip other than those set out in this consent and
waiver.

I am 18 years of age or more and I have read and understand the terms of this
Parental/Guardian Consent Form and Liability Waiver and recognize that it is binding upon
me, my heirs, executors, and administrators.

Name of Parent/Guardian Signature

Date Signed: Contact Number:

Name of Child/Student Signature

Date Signed: Contact Number:

This space is for notary public