WAIVER

(Informed Consent)

I, ________________________________________________ , ____ years old, acknowledge

(Name of Student)

that I wish to enroll in the __________________________________ of ADNU.

(Name of Program)

I understand that I will participate in the Limited Face-to-Face Classes that will be conducted
by the Ateneo de Naga University.
I understand that certain risks are inherent in the conduct of the said classes in which I will
participate and I fully accept those risks. This risk includes, but not limited to, disease development. I
understand that there may be a great variety of other risks not known or reasonably foreseeable. I
acknowledge that Ateneo de Naga University is not responsible for any harm that might occur arising
from or connected to the face to face classes.
I acknowledge that I have to comply with the additional corroboration/s prior to enrolling in the
program and submit it/those to the Office of Student Affairs to ensure that I am fit to enroll/continue
the program.
I understand that once I am officially enrolled, the College/School will impart regular updates
to my parents/official guardian with regard to my academic standing, psycho-emotional and
physiologic well-being, and other pertinent information to ensure faithful supervision on me.
I understand that I have to perform other functions as may be defined related to compliance
with government regulations and issuances due to the fluid situation of the pandemic.
I fully release and discharge Ateneo de Naga University from all liability in connection with
my participation in the limited face-to-face classes.
In so making this waiver, I understand that I cannot commence an action against Ateneo de
Naga University and/or its officers, before any and all fora.

_________________________________________
Signature Over Printed Name Of Student

ACKNOWLEDGEMENT

Republic of the Philippines )

____________________________ ) S.S.

Before me, this _____ of ___________________ , 2022 personally appeared

_________________________________________ and _________________________________________

(Signature over Printed Name of Student) (Signature over Printed Name of Parent/Official Guardian)

with government-issued identification numbers _____________________________________ , ___________________

(Government Issued ID No. of the student) , (Government Issued ID No. of Parent/Guardian)
known to me to be the same persons who executed this waiver/informed consent and who
acknowledged to me that the same is their free act and deed.

Witness my hand and seal.

Doc. no.: _____________

Page no.: _____________ Notary Public
Book no.: _____________
Series of: _____________