Republic of the Philippines

SORSOGON STATE UNIVERSITY

OFFICE OF THE STUDENT DEVELOPMENT AND SERVICES
Student Council Affairs Unit
Magsaysay St., Sorsogon City, Sorsogon 4700, Philippines
ISO CERTIFIED
9001:2015

PARENTS’/GUARDIANS’ PERMIT FORM

Semester, S.Y.

TO WHOM IT MAY CONCERN:

This certifies that I am allowing my son/daughter, ____________________________________,

(Name of Student)
_____________________to participate and or attend in the Local Off-Campus Activity on ,
(Course/Year/Section)

2022 in .

I am fully aware that I will be responsible to his/her personal conduct while he/she is on Local Off-
Campus Activity and shall be liable thereof in consonance with the pertinent provisions of the Student
Handbook and CMO No. 63, series of 2017.

_____________________________ __________ ____________________________ _______

Parent/Guardian Signature Over Printed Name Date Parent/Guardian Signature Over Printed Name Date

Further, safety precautionary measures have been instituted by the faculty members accompanying the
event.

ELMER P. ESPLANA __________ REYNANTE ESPINEDA _______

Faculty Signature Over Printed Name Date Faculty Signature Over Printed Name Date

OLIVER F. GARBIN __________ LIZEL D. LERIOS _______

Faculty Signature Over Printed Name Date Faculty Signature Over Printed Name Date

__________________________ __________ ____________________________ _______

Faculty Signature Over Printed Name Date Faculty Signature Over Printed Name Date

SUBSCRIBE AND SWORN TO BEFORE ME this _____________ day of _____________________, 20 ______ at

_____________________________________ Philippines.

Notary Signature: ______________________

Notary Printed Name: __________________
My commission expires: _________________

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