Don Mariano Marcos Memorial State University

South La Union Campus

COLLEGE OF COMMUNITY HEALTH AND ALLIED MEDICAL SCIENCES
Agoo, La Union
Embracing World-class Standards Tel. 072.682.06.63 Care to learn, learn to care

PARENT CONSENT

I hereby allow my son/daughter _______________________________ to join and participate in

the COMMUNITY DUTY on October 27,28- November 3-4, 2022 at Macalva Norte, Agoo, La Union
and I understand that DMMMSU-CCHAMS shall not be held liable for any untoward incident that may
happen to my son/ daughter which is beyond the control of the organization.

_____________________ _________________________
Date Signature over Printed Name

SCHOOL CONSENT

We hereby allow our student _________________________ to join and participate in the

COMMUNITY DUTY on October 27,28- November 3-4, 2022 at Macalva Norte, Agoo, La Union and
we understand that DMMMSU-CCHAMS shall not be held liable for any untoward incident that may
happen to my son/ daughter which is beyond the control of the organization.

___________________ ____________________________
Date Signature over Printed Name
(Adviser)

___________________ ____________________________
Date Signature over Printed Name

(Clinical Instructor)

___________________ ____________________________
Date Signature over Printed Name
(Dean)