RIZAL PROVINCIAL HOSPITAL SYSTEM

T. Claudio Brgy. San Juan Morong, Rizal

PARENT’S CLEARANCE AND

WAIVER FORM

This is to certify that I am allowing my son/daughter Abegail J. Reyes to go

on a hospital internship for Two (2) weeks from Apr 11-13 to Apr 18-20 at Operating

Room,

RIZAL PROVINCIAL HOSPITAL SYSTEM

It is understood that Abegail J. Reyes will follow the policies and guidelines set by Hospital
Institution, and abide by the rules and regulations that may be imposed by the department-
in-charge for her welfare and safety.
I fully agree waive any responsibility on the part RIZAL PROVINCIAL HOSPITAL
SYSTEM and the department-in-charge in case of any untoward incident/exposure or
acquisition of any infections or viral diseases like COVID-19 that may happen to
Abegail J. Reyes in the duration of the internship.

Student Signature
Name of the Student Abegail J. Reyes
Signature of Parents/Guardian
Name of Signatory Marianne T. Jesuitas
Relationship of Signatory to Intern Mother
Date Signed April 7, 2022
Received by:

_____________________________
1. The student name who signed must be matched on the sent documents of the school in their
communication letter.
2. In the event that a parent cannot sign the waiver form, It must be signed by the legitimate
guardian, attested by the college dean.
3. This document must be dated, signed and submitted within the first week of the internship.