Republic of the Philippines

CATANDUANES STATE UNIVERSITY

COLLEGE OF HEALTH SCIENCES
Virac, Catanduanes

CONSENT

Ako si_______________________________, nagtugot ki____________________________

(Guardian) (Client)
na umiba sa 3rd year Nursing Student para sa saindang Psychiatric Nursing Clinical Experience sa
Catanduanes State University CHS Building lunes hanggang biyernes ________________sa laog nin
limang aldaw . (oras)

___________________________________ _____________________________
Name of Parent/Guardian Name of Student

--------------------------------------------------------------------------------------------------------------------------------------
WAIVER

We hereby waive any claim from the Clinical Instructor/Nursing Students who handle
Psychiatric Nursing for any accident that might happen beyond human control, in connection with
his/her participation in all psychiatric nursing activities being conducted at the CatSU-CHS Building
from Monday to Friday_______________, from_____________to_____________, 2022.

It is however enjoined that utmost care, attention, precaution, and health protocol will be
observed by all concerned.

____________________________ ____________________________________
Name of Client Name of Parent/Guardian

____________________________________
Name of Student

MARILYN B. PANTI, Ed.D MARIANNE L. CASTILLA, Ed.D JOHN F. VILLEGAS, Ph.D

Clinical Instructor Clinical Instructor Clinical Instructor

JANET B. LIM, MAN

Dean
 Republic of the Philippines
CATANDUANES STATE UNIVERSITY
COLLEGE OF HEALTH SCIENCES
Virac, Catanduanes

CONSENT

Ako si_______________________________, nagtugot ki____________________________

(Guardian) (Client)
th
na umiba sa 4 year Nursing Student para sa saindang Psychiatric Nursing Clinical Experience sa
Catanduanes State University CHS Building lunes hanggang biyernes ________________sa laog nin
limang aldaw . (oras)

___________________________________ _____________________________
Name of Parent/Guardian Name of Student

--------------------------------------------------------------------------------------------------------------------------------------
WAIVER

We hereby waive any claim from the Clinical Instructor/Nursing Students who handle
Psychiatric Nursing for any accident that might happen beyond human control, in connection with
his/her participation in all psychiatric nursing activities being conducted at the CatSU-CHS Building
from Monday to Friday_______________, from_____________to_____________, 2022.

It is however enjoined that utmost care, attention, precaution, and health protocol will be
observed by all concerned.

____________________________ ____________________________________
Name of Client Name of Parent/Guardian

____________________________________
Name of Student

JOCELYN LL. JORDAN, Ed.D JULIE ANN T. VEGA, MAN GLENDA C. TENERIFE, MAN
Clinical Instructor Clinical Instructor Clinical Instructor

JOEL T. OLFINDO, MAN JANET B. LIM, MAN

Clinical Supervisor Dean