DHVSU-SAS-OCS Form 003

PARENTAL/GUARDIAN CONSENT

_______________
Date
To whom it may concern:
I, Lea C. Fajardo (Parent/Guardian’s Name), hereby permit my
son/daughter/ward Kristine C. Fajardo (Name of Student), of legal age and a bonafide
student of DON HONORIO VENTURA STATE UNIVERSITY currently taking up
Bachelor of Science in Elementary Education, BEEd 4-A (Course/Year/Section) to
undergo Student Internship Program in the Philippines (SIPP) as one of the course
requirement of the program.

I agree that the Don Honorio Ventura State University (DHVSU) and the Host
Training Establishment (HTE) where my son/daughter/ward has to undertake an
Internship are not, in any way, liable for any untoward incident or injury that may arise
while undergoing internship.

1.
Name of HTE: San Pablo 2nd Elementary School
Address of HTE: San Pablo 2nd, Lubao, Pampanga
2.
3.
Nature of Training: Education/Training Internship
4.
Period of Training: February – May, 2023
5.
Number of hours to be spent daily _6_ hours a day or an equivalent of _600_
hours.
I further waive my rights for any damages and liabilities and do not hold the University
and the Host Training Establishment accountable whatsoever.

UNDERTAKING
Considering the foregoing premises which have been fully explained to us by our
son/daughter/ward, I hereby allow him/her to join the foregoing activity.

_____________________________
Signature of Parent/ Guardian
Address of Parent/Guardian: Sitio Arabia, San Pablo 2nd, Lubao, Pampanga
Contact Number of Parent/Guardian: 09300864928
Contact Number of Student: 09500676277
DATA PRIVACY CONSENT
I allow DHVSU through the Office of Career SUBSCRIBE AND SWORN to before me this, ____
Services to collect record, organize, update or
modify, retrieve, consult, utilize, consolidate,
day of February 2023, at ____________________
block, erase or delete any information which
are a part of my personal data for historical, NOTARY PUBLIC Doc.
statistical, research, and evaluation purposes
pursuant to the provisions of the Republic Act
No. _______________
No. 10173 of the Philippines, Data Privacy Act Page No. ___________
of 2012 and its corresponding Implementing Book No. ___________
Rules and Regulations.
Series of 2023
______________________________
Signature of Student

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 DHVSU-SAS-OCS Form 003

NOTE: PLEASE ATTACH PHOTOCOPY OR VALID I.D. OF PARENT/GUARDIAN for

NOTARY purposes.

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