WAIVER

(Informed Consent)

I, Miguel Antonio O. Dizon, 22 years old,

(NAME OF STUDENT) (AGE)

acknowledge that I wish to enroll in the BS PSYCHOLOGY program of ADNU.

(NAME OF PROGRAM, e.g. BS BIOLOGY, BS CIVIL ENGINEERING, etc.)

I understand that I will participate in the Limited Face-to-Face Classes that will be conducted by
the Ateneo de Naga University.
I understand that certain risks are inherent in the conduct of said classes in which I will
participate, and I fully accept those risks. This risk includes, but not limited to, disease development. I
understand that there may be a great variety of other risks not known or reasonably foreseeable. I
acknowledge that Ateneo de Naga University is not responsible for any harm that might occur arising
from or connected to the face to face classes.
I understand that I should obtain a medical insurance coordinated by the University that covers
limited medical expenses related to COVID-19. Correspondingly, I acknowledge that I have to comply
with the additional corroboration/s prior to enrolling in the program and submit it/those to the Office of
Student Affairs to ensure that I am fit to enroll/continue in the program.
I understand that once I am officially enrolled, the College/School will impart regular updates
to my parents/official guardian with regard to my academic standing, psycho-emotional and
physiologic well-being, and other pertinent information to ensure faithful supervision on me.
I understand that I have to perform other functions as may be defined related to compliance
with government regulations and issuances due to the fluid situation of the pandemic.
I fully release and discharge Ateneo de Naga University from all liability in connection with my
participation in the limited face-to-face classes.
In so making this waiver, I understand that I cannot commence an action against Ateneo de
Naga University and/or its officers, before any and all fora.

(SIGNATURE OVER PRINTED NAME OF STUDENT)

ACKNOWLEDGEMENT

Republic of the Philippines )

) S.S.

Before me, this of , 2022 personally appeared

and
(Printed Name of Student) (Printed Name of Parent/Official Guardian)

with government issued identification numbers ,

(Government Issued ID No of the Student), (Government Issued ID No. of Parent/Official Guardian)
known to me to be the same persons who executed this waiver/informed consent and who acknowledged
to me that the same is their free act and deed.

Witness my hand and seal.

Doc. no.:
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