DAVAO ORIENTAL

STATE UNIVERSITY
PARENT’S CONSENT

REPUBLIC OF THE PHILIPPINES }

DOrSU, City of Mati, Davao Oriental } S.S.
x-----------------------------------------------x

AFFIDAVIT OF CONSENT

I/We ___________________________________________________ the parent(s)/guardian(S) of

(Name of Parent(s)/Guardian)
_____________________________________ do hereby grant permission for his/her participation in the
(Name Of Student)
_____________________________________________ to be held on ____________________________
(Naure of the Activity) (Date).

At ___________________________________________________________________________.
(Venue)

I hereby warrant to the best of my knowledge, he/she is in good health, and I assume all
responsibility for his/her health. In the event of an emergency, I hereby give permission to transport
him/her to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any
further treatment by the hospital or doctor. In the event of an emergency and you are unable to reach me,
contact:

_______________________________ at ____________________.
(Name and Relationship ) (Phone Number)

IN WITNESS HEREOF, I have hereunto set my hand this ___________________________at

City of Mati, Davao Oriental, Philippines.

_____________________________________
Affiant

SUBSCRIBE AND SWORN to before me, this _____________________at City of Mati, Davao
Oriental, Philippines. Affiant exhibited me his/her _______________________issued at
____________________________________Philippines on _______________.

Doc No. ________: Notary Public __________:

Page No. ________: Until __________:
Book No. _______ : PTR No. __________:
Series of: ________. At ___________, Davao Oriental