Revision No: Revision No:

Revision Date: Revision Date:

ACTIVITY INFORMATION & CONSENT ACTIVITY INFORMATION & CONSENT

Importan Information:
- THIS FORM SHOULD BE FILLED-OUT BY THE PROPONENT(S) OF THE SERVICE-LEARNING OR COMMUNITY
ENGAGEMENT INITIATIVE OR BY CSCE.
- THIS FORM SHOULD BE DULY ACCOMPLISHED BEFORE THE ACTUAL CONDUCT OF THE FIELDWORK
ACTIVITY RELATED TO A SERVICE-LEARNING OR COMMUNITY ENGAGEMENT INITIATIVE.
- USE THE SPACE PROVIDED FOR REMARKS TO INDICATE SPECIAL INSTRUCTIONS / REQUESTS /
IMPORTANT INFORMATION / REQUIREMENTS BY CONCERNED INDIVIDUALS
Importan Information:
- THIS FORM SHOULD BE FILLED-OUT BY THE PROPONENT(S) OF THE SERVICE-LEARNING OR COMMUNITY
ENGAGEMENT INITIATIVE OR BY CSCE.
- THIS FORM SHOULD BE DULY ACCOMPLISHED BEFORE THE ACTUAL CONDUCT OF THE FIELDWORK
ACTIVITY RELATED TO A SERVICE-LEARNING OR COMMUNITY ENGAGEMENT INITIATIVE.
- USE THE SPACE PROVIDED FOR REMARKS TO INDICATE SPECIAL INSTRUCTIONS / REQUESTS /
IMPORTANT INFORMATION / REQUIREMENTS BY CONCERNED INDIVIDUALS

TITLE OF SERVICE-LEARNING / COMMUNITY TITLE OF SERVICE-LEARNING / COMMUNITY

ENGAGEMENT INITIATIVE ENGAGEMENT INITIATIVE

DATE(S) & TIME(S) OF THE ACTIVITY DATE(S) & TIME(S) OF THE ACTIVITY

LOCATION LOCATION

FACULTY / EMPLOYEE / FACILITATOR-IN- FACULTY / EMPLOYEE / FACILITATOR-IN-

CHARGE CHARGE

DECSRIPTION OF THE ACTIVITY DECSRIPTION OF THE ACTIVITY

REMARKS REMARKS

Signature over Printed Name of Student Signature over Printed Name of Student
(include course & section for SL/NSTP (include course & section for SL/NSTP
activities activities

I, the undersigned, have reviewed all of the above information and have approved of the details and itinerary. I am aware of the I, the undersigned, have reviewed all of the above information and have approved of the details and itinerary. I am aware of the
risks inherent in participating in this activity. I hereby give my permission for my son/daughter to participate in this activity. risks inherent in participating in this activity. I hereby give my permission for my son/daughter to participate in this activity.

SIGNATURE OVER PRINTED NAME SIGNATURE OVER PRINTED NAME

CONTACT DETAIL(S) OF CONTACT DETAIL(S) OF
OF PARENT/ GUARDIAN AND OF PARENT/ GUARDIAN AND
PARENT / GUARDIAN PARENT / GUARDIAN
DATE SIGNED DATE SIGNED

COPY: (1) PARENT OR GUARDIAN; (2) CSCE FORM CSCE-002 COPY: (1) PARENT OR GUARDIAN; (2) CSCE FORM CSCE-002

THIS FORM IS AVAILABLE AT THE CENTER OF SERVICE-LEARNING AND COMMUNITY ENGAGEMENT. THIS FORM IS AVAILABLE AT THE CENTER OF SERVICE-LEARNING AND COMMUNITY ENGAGEMENT.