PARENTAL/GUARDIAN CONSENT FORM FOR LIMITED FACE-TO-FACE BMLS INTERNSHIP

BSMLS Intern’s Name: ___GOTOH, AARON TZERGIO CERRER_____________________________

Parent’s/Legal Guardian’s Name: __________ANA LIZA CERRER______________________

Home Address: _____7A LEXBERVILLE BALACBAC ROAD STO. TOMAS

PROPER________________________________________

I, ___ANA LIZA CERRER____________________________, parent/legal guardian of ____AARON TZERGIO

CERRER GOTOH_____________________ , grant

permission for my child/ward to undertake the limited face-to-face Medical Technology clinical

internship at ______________________________.

As parent and/or legal guardian,

1. I understand that the honing of laboratory skills and community-related skills are best achieved in a
real laboratory setting;
2. I am fully aware of the University of Baguio-School of Natural Sciences’ Policies, Procedures and
Guidelines (PPG) for limited face-to-face BMLS clinical internship;
3. I trust that the University of Baguio will make sure that the clinical laboratory (room/space,
manpower and patient/specimen-contact procedures) are all compliant to CHED and IATF guidelines.
4. I know that the University of Baguio will take all reasonable care and necessary precautions to ensure
the maintenance of a healthy laboratory environment; and
5. that I shall be one with the University of Baguio in monitoring my child’s/ward’s academic progress
and medical condition.

I wish to be advised of my child’s/ward’s condition in the event of any emergency and/or health
problem while on clinical duty through this contact number/email address:
____09173756869_____________

__________ANA LIZA_CERRER________________________
Name and Signature of Parent/Legal Guardian

*Please attach photocopy of a valid ID

Notary Public