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 6-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 ________ _________________________

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

_____________________________ ____________
Signature of the Student Participant Date

____________________________ ____________
Signature of Parent/Guardian Date

PROF. MARILOU T. AVENDAŇO __________

EED Student Teaching Coordinator 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: ____________________________________________________

Student Contact Number: _____________________

In event of illness or accident, please notify:

Name: ______________________________ Relationship to Student: _____________
Address: _____________________________________________________________
Contact Number: _________________

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

Philippines.