LEYTE NORMAL UNIVERSITY

Tacloban City
OFFICE OF THE VICE PRESIDENT FOR
STUDENT DEVELOPMENT AND AUXILIARY SERVICES
vpsdas@lnu.edu.ph
053 888 0855 local 260

PARENTS’/GUARDIANS’ PERMIT FORM

______Semester,
SY_______
PLEASE TAKE NOTE OF THE FOLLOWING:
1. Please fill out this form in BLOCK LETTERS and in triplicate.
2. ALL sections MUST BE FILLED OUT COMPLETELY.
3. Permits for Educational Tour/Field Trip purposes and for a participant who is a minor should be notarized.
4. If the student involved is a MINOR, BOTH parents MUST sign the permission form.

To Whom This May Concern:

I/We, _____________________________ & _________________________________, parent/s/legal guardian/s of ___________________
__________________________________________, a student under the College of ___________________________________________________
(Student’s Name)
with Student Number_______________, hereby give/s permission to my/our daughter/son/ward to participate/to attend the ___________________
______________________________________________ in _______________________________________ on _________________________.
(Event/Activity) (Place/Venue) (Date)
I/We was/were made aware that the faculty member/s listed below will accompany him/her in the travel/activity and that adequate
precautionary measures are undertaken to ensure the safety of my/our child/ward.
Printed Name of Faculty Faculty Signature

1. ________________________________________ ____________________________________
2. ________________________________________ ____________________________________
3. ________________________________________ ____________________________________
4. ________________________________________ ____________________________________
5. ________________________________________ ____________________________________

Further, I/we fully understand that I/we cannot hold the university administrators and instructors liable for any unforeseen/untoward
incidents beyond our control.
IN WITNESS WHEREOF, I/We have hereunto set my/our hand/s this ______________________in ______________________________,
(Date) (Place)
Philippines.
________________________________________ ________________________________________
Name and Signature of Parent/Guardian #1 Name and Signature of Parent/Guardian #2
________________________________________ ________________________________________
Complete Address Complete Address
________________________________________ ________________________________________
Contact Number Contact Number
________________________________________ ________________________________________
ID Type & Number ID Type & Number

J U R A T

SUBSCRIBED AND SWORN TO before me this _______________________________ in __________________________________

(Date) (Place)
Philippines, affiant/s exhibiting to me the above-mentioned identification card/s as competent evidence of identity.

DOC. No. _________________

PAGE No. _________________
BOOK No._________________
SERIES OF_________________ Notary Public

F-SDM-013 (09-02-19)_______________________________________________________________________________