Republic of the Philippines

BULACAN STATE UNIVERSITY

City of Malolos, Bulacan

COLLEGE OF NURSING
PARENTAL CONSENT FORM
Name of Student: _Madriaga, Clarence C._____ Student Number: _2019112787__
Course: ___Bachelor of Science in Nursing____________ Year & Section: __4D_______
Name of Activity: HOSPITAL DUTY and COMMUNITY DUTY
Nature of Activity:
HOSPITAL and COMMUNITY DUTY

Venue: Inclusive Dates:

Brgy. Iba Ibayo- Community Duty Feb. 15,16, 22, 23 and 23, 2023
Ofelia Mendoza General Hospital-All Areas Feb 28, Apr 1,7 and 8, 2023
Brgy. Iba Ibayo- Community Duty Mar. 22, 23, 29 and 30, 2023
San Pascual Baylon General Hospital- All Areas Apr. 18, 19, 25 and 26, 2023

To be filled-up by Parent/Guardian:
( ) I allow my son / daughter to attend the activity.
I trust that the organizers of this activity will take due to diligence to ensure the safety
of my son / daughter as a participant. I also agree to absolve the university from legal
responsibility on any untoward incident in the course of event.
( ) I do not allow my son / daughter to attend the activity.

Name of Parent / Guardian: ______________________________________________

Phone / Cell phone number (s): ___________________________________________

Address: _____________________________________________________________

Specimen Signatures: _____________ _____________ ______________

Note:
● This Parental Consent Form must be notarized (if the activity will be held outside
Bulacan)
● Attach a photocopy of the Parent’s/ Guardian’s identification card with signature.