College of Nursing

Valenzuela Quezon City Antipolo Pampanga Nueva Ecija

CONSENT FORM AND WAIVER FOR CLINICAL DUTIES/PRACTICUM

This consent form and waiver is executed by ________________________________________ for

NAME OF PARENT/GUARDIAN
and in behalf of _____________________________________________, a resident of
NAME OF STUDENT
_____________________________________________________________________________, who is
STUDENT’S ADDRESS
required to actively participate and attend all clinical duties/rotations and practicum exposure as mandated

by the curricular requirements of the course enrolled in.

The undersigned recognize and affirm that the Our Lady of Fatima University conforms to the

curricular program of the Commission on Higher Education and that, therefore, the University is not liable

for any untoward and unforeseen incident/illness that may occur as a result of the clinical duty/practicum

rotation; whether on-site or going to and from the affiliation/practicum site.

This consent form and waiver shall be valid up to the student’s completion of the Bachelor of

Science in Nursing program. This document was signed on the _____th day _____________, ________.
DAY MONTH YEAR

_______________________________ _________________________________

STUDENT’S SIGNATURE PARENT/GUARDIAN’S

OVER PRINTED NAME SIGNATURE OVER PRINTED NAME