EASTERN VISAYAS STATE UNIVERSITY

Tacloban City
Control No. EVSU-
Title of Form: Waiver Revision No. 0
Date

Name of Activity Teaching Internship

Type of Activity Off-campus Teaching Internship Deployment
Place of the Activity Tacloban City Division
Date/s of Activity March 06 - May 15, 2023

I hereby grant permission to my son/daughter to participate the above mentioned activity.

I fully understand that all the necessary precautions will be taken into consideration to ensure the
safety and wellbeing of my son/daughter for the duration at the said activity. However, I cannot
hold the chaperon/instruction/companion at the school responsible for any on toward incident or
unforeseen event that may happen beyond control I hereby release and discharge the above
named sponsor from all liability arising out of or in connection with the Above-describe activity.

Name of student participant _____SHARLY I. GUILLERA______

I/WE HEREBY AGREE that the student participant will comply with all of the above statements
listed.

____SHARLY I. GUILLERA____ ____________

Signature of the Student Participant Date

____SHARON I. GUILLERA____ ____________

Signature of Parent/Guardian Date

MARILOU T. AVENDAŇO, M.A. Phil. Stud ____________

EED Student Teaching Coordinator Date

BRYAN H. GERVACIO, Ph.D. ____________

Head, Elementary Education Department Date

LILIBETH D. ALIDO, Ph.D. ____________

Head, Field Study and Student Teaching Department Date

HERMINIGILDO S. BADION, Ed.D ____________

Dean, College of Education Date

Student Address:_ Sitio Magaobao, Brgy. Sta. Cruz, Jaro, Leyte__

Student Contact Number: _09672514376__

In event of illness or accident, please notify:

Name: __Sharon I. Guillera____ Relationship to Student: __Mother_______
Address: __ Sitio Magaobao, Brgy. Sta. Cruz, Jaro, Leyte________
Contact Number: ___09384458002____

SUBSCRIBE AND SWORN before me this _____ day of ____________ at ________________

Philippines.