Republic of the Philippines

TECHNOLOGICAL UNIVERSITY OF THE PHILIPPINES

College of Industrial Education
Ayala Boulevard cor. San Marcelino St., Ermita, Manila 1000
Telefax (02) 523-2293, Tel Nos. (632) 521-4063, Website: http://www.tup.edu.ph/

INFORMED CONSENT FORM

Kindly read this informed consent form carefully. By signing this form, you are agreeing to allow your work
and/or output as a student as well as feedback to be used for educational purposes (course evaluation, presentation in
scholarly conferences and publications) with proper attribution.

This document gives Ms Dianne Villar of Technology for Teaching and Learning 2 Faculty-in-Charge or FIC –
henceforth referred to as TTL-2 – permission to use works created by (insert Student’s Name) in this course.
This does not mean that the abovementioned student will lose ownership rights over his/her works – simply that TTL-2
has your permission to use your works for the purposes mentioned.
1. I give permission for my works created in this course to be used for purposes of course evaluation, presentation
in scholarly conferences and publications, with proper attribution.
2. The TTL-2 understands that I own the intellectual property rights for my works, and that this consent form is not
meant to transfer my ownership.
3. I under stand that my works may be kept on file for an indefinitie period of time and that they may be used in the
future for the purposes listed in item 1.
4. I understand that no payment is involved for giving this permission.
5. If I decide to withdraw my permission at any time, I understand that it is my responsibility to contact the TTL-2
FIC and inform him/her of my decision in writing.

Student’s Name: Signature:

Date:

Adapted from Prof. Niño D. Naldoza sample consent form