UNIVERSITY OF ST.

LA SALLE
College of Nursing

GUARDIAN/PARENTAL APPROVAL
(Parental Waiver)

________________
Date

To Whom It May Concern:

This is to certify that I hereby willingly and voluntarily consent to the participation of my
son/daughter, Mr./Ms. __________________________________ in attending to his/her
limited face-to-face activity in the:

 Skills laboratory (in campus)

 Clinical experience in:
Bacolod City Health Office
Bago City Hospital (BCH) – OB Ward, Delivery Room and Nursery
Bago City Health Office (BCHO) – Lying-In Clinic
Barangay Health Center – Selected Barangays in Bacolod City
Community Health Nursing (CHN) – Selected Barangays / Communities in
Bacolod City
Corazon Locsin Montelibano Memorial Regional Hospital (CLMMRH) – OB
Ward, Delivery Room and Nursery
Teresita Lopez Jalandoni Provincial Hospital (TLJPH) - OB Ward, Delivery
Room and Nursery
The Doctor’s Hospital Incorporated (TDHI) - OB Ward, Delivery Room and
Nursery

this Academic Year 2022-2023 with the following schedules:

Time of RLE Class/Exposure:

Skills laboratory (7:30 AM-1:30 PM)

Clinical Duty
Bacolod City Health Office (BCHO) – 7:30am – 3:30pm
Bago City Hospital (BCH) – OB Ward (6am – 2pm), Delivery Room and
Nursery (6am – 2pm)
Bago City Health Office (BCHO) – 8am – 4pm
Barangay Health Center – 7am – 3pm
Community Health Nursing (CHN) – 7am – 3pm
 Corazon Locsin Montelibano Memorial Regional Hospital (CLMMRH) –
6am – 2pm / 2pm – 10 pm
Teresita Lopez Jalandoni Provincial Hospital (TLJPH) – 6am – 2pm / 2pm –
10pm
The Doctor’s Hospital Incorporated (TDHI) – 6am – 2pm / 2pm – 10pm

I have considered the benefits that my son/daughter will derive from his/her
participation in this limited face-to-face activity. With the understanding that I will not hold any
party responsible for any untoward incident or infection which may happen to my
son/daughter during the above-mentioned activity as long as due care and precautions are
observed to ensure the safety of the students.

I hereby release University of St. La Salle, its Administration, Faculty and the Affiliating
Agency from any responsibility for all consequences, which may result by my decision under
these circumstances

Affixed is my signature this ________ day of ____________________________at

____________________________.

__________________________________
____________________________________

FOR FACULTY USE ONLY: Printed Name of Parent/Guardian

Faculty Supervising the Student: _________________________________

Signature of Parent/Guardian

1. _______________________________ ___________________________________
Address
2. ______________________________
Contact No.______________________________
3. ______________________________