Northwestern Visayan Colleges

OFFICE OF THE VICE PRESIDENT FOR ACADEMIC AFFAIRS

NVC ASQ Building, 2nd Floor Room 204, Capitol Site, Kalibo, Aklan
nvckalibo_op@yahoo.com www.nvc.edu.ph

CONSENT FORM FOR THE LIMITED FACE-TO-FACE ACTIVITIES

Introduction: Please complete the following, sign and return to. For graduate school students it
should be signed by the parent/guardian, spouse, or the student himself.
________________
Instructor
NAME OF STUDENT: PROGRAM: AGE:
_______________________________________ ________________ _______
Name of (Parent/Guardian,
Spouse):__________________________________________________
Address: _________________________________________________________________
Mobile: __________________________________________________________________
Family Doctor (Optional): ______________________Doctor’s Tel No: ________________
Does your child suffer from any medical conditions/ allergies that the teacher/ coach should be
aware of (including any current medication)
………………………………………………………………………………………………………
……………………………………………..
………………………………………………………………………………………………………
……………………………………………..
Please provide details of medication that must be administered:

Emergency contact details :( If different from above)

Name: Telephone no:
Relationship to Student:

CONSENT (Please read carefully)

a.) I agree to my _____________ taking part in the (limited face-to-face consultation, work
immersion, practicum, laboratory work) in partial fulfillment of the subject ________________________
to develop the independent and critical skills of the students.
b.) I confirm to the best of my knowledge that my ______________ does not suffer from any
medical condition other than those listed above.
c.) I fully support the (limited face-to-face consultation, work immersion, practicum, laboratory
work) undertaking of my son/daughter through minimal financial cost and through my attendance/
presence if so desired.
d.) I consent to my son/daughter travelling by any form of public transport, minibus or motor vehicle
in the course of the said activity.
e.) I understand the risk associated with COVID transmission to my child during attendance based
on the attached schedules of the activity.
Signed: ______________________________
(Signature over printed name)
Date: