B ic ol Permit Form

Parents’ /Guardians’ U n iv er s it y Legazpi City, Philippines

semester, SY

PLEASE TAKE NOTE CAREFULLY

1. Please fill up this form in BLOCK LETTERS.
2. ALL sections MUST BE COMPLETED when applicable.
3. Permit should be duly NOTARIZED for Educational Tour/Field Trip purposes and when participant is a minor.

TO WHOM THIS MAY CONCERN

This certifies that ,a _
(Course and Year)

of the College of with Student No. has the

his/her undersigned parent(s)/guardian(s) to participate and/or attend in the
on , 20
in .

This certifies further that risk assessment plans and necessary safety and precautionary
measures have been instituted.

Further, that the following faculty members shall accompany him/her in the travel.
1.
Faculty Name (Please print) Faculty Signature

2.
Faculty Name (Please print) Faculty Signature

3.
Faculty Name (Please print) Faculty Signature

4.
Faculty Name (Please print) Faculty Signature

Note: If the student is a minor, both parents MUST sign the permission form.
I/We have honestly and accurately completed all parts of the Parents’/Guardian’s
Permit Form to the best of my/our ability.

Parent/Guardian Signature #1 Date Parent/Guardian Signature #2 Date

Parent/Guardian Name (please print) Parent/Guardian Name (please print)

Complete Address Complete Address

Contact Numbers Contact Numbers

JURAT

On , of 20
_, before me personally appeared, and
to me known to be the individual, or individuals
described in and who executed the within and foregoing instrument, and acknowledged that
he/she/they signed their free and voluntary act and deed, for the uses and purposes therein
mentioned.

Given under my hand and official seal this day of , 20 .

Notary Signature: Affix

BU OSS S A S seal
BU-F-OSS-34
here

Effectivity: September
Notary Printed Name13, :2012 Revision No.
1
My commission expires:

Office of Student Services

Student Activities Section

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