RELEASE LIABILITY AND WAIVER FORM

The undersigned parent/s/guardian whose printed name/s and signature/s appear below hereby
declare and state:

1. I/we am/are the pare/s/guardian of:

NAME OF PARTICIPANT: VEENAH MARIE A. BORJA

2. A bona-fide resident of
Complete Address: BRGY. 3, SAN PEDRO, VINTAR, ILOCOS NORTE

3. Are aware that said participant will be a part if activity of province as follows:
a. Destination: Ilocos Norte Youth Development Office
b. Purpose: To attend the orientation of the LiNKS 2022 Junior Officials
c. Inclusive dates/Time: August 10, 2022 from 9:00AM to 1:00PM

4. I hereby assume all of the risks of participating in this activity, and waive release and
discharge the Provincial Government of Ilocos Norte (PGIN), Ilcoos Norte Youth Development
Office (INYDO), organizers, officials, members, volunteer and all liability, including but not limited
to, for my death, disability, personal injury, property damage, property theft, or actions of any kind
which may occur to me as a result of participation in the above name activity.

I agree to indemnify, hold harmless, and promise not to sue the entitles or persons mentioned above
from any and all liabilities or claims made as a result of part of participation in the above name
activity.

We verified all the information/data herein provided and they are true and correct to our own
personal information and belief.

____________________________ VEENAH MARIE A. BORJA

PARENT/GUARDIAN PARTICIPANT

PERMANENT ADDRESS: __ BRGY. 3, SAN PEDRO, VINTAR, ILOCOS

NORTE______________
CONTACT NUMBER in case of Emergency: _______________________________________

_____________________________________________________
INYDO STAFF

Ilocos Norte Centennial Arena, South Wing, Ground Floor, 2900 Laoag City | Telephone No.: 670-70-48
Facebook Page: www.facebook.com/SiribExpress | E-mail Address: ilocosnorteydopgin@gmail.com