Republic of the Philippines

PALOMPON INSTITUTE OF TECHNOLOGY TABANGO

Tabango, Leyte

GENERAL AND TEACHER EDUCATION UNIT

AFFIDAVIT OF WAIVER

I/We, Mr. ______________________ and Mrs. _________________________ parents/ guardian of

_______________________, a Student of the Palompon Institute of Technology Tabango, Tabango, Leyte,
has/have hereunto voluntarily grant permission for him/her to undergo Field Study Deployment in
___________________________________ which is one of the major course requirements in his/her
curricular program.

That I/we made it known my/our continued financial and moral support to him/her during the Pre-
Servoce Internship. That I/we shall adhere to any disciplinary action of the College Authorities, such as
dropping him/her from the rolls of Pre-Service Student and/or barring him/her from passing the Prof. Ed 11 -
FS 1 (observations of Teaching-Learning in Actual School Environment and Prof. Ed. 12 - FS 2
(Participation and Teaching Assistanship should it be found that he/she is a frequent absentee and/or a
notoriously undesirable Pre-Service Student. I/We are also fully aware on the imminent danger of the current
global health situation brought about by Covid-19.

WAIVER

THIS IS TO CERTIFY that the Palompon Institute of Technology Tabango and its Cooperating
Schools are in no way responsible nor shall pay compensation for any accident, harm, injury, or any CoVid-
19 and other related incidents that may be caused on our son/daughter during the internship, unless all
precautionary and preventive measures are being implemented to prevent any accident to happen.

It is fully known that we have read and understood all the contents of the parent consent and waiver
and have signed the same with our voluntary act and deed.

Signed this ____day of _________________ in ______________, Leyte, Philippines.

_____________________________ _____________________________
Signature of Father/Guardian Signature of Mother/Guardian

SUBSCRIBED AND SWORN TO before me this _____ day of ______________ at Palompon

Institute of Technology Tabango, Tabango, Leyte, Philippines.

Notary Public

Doc. No. ______

Page No. ______
Book No. ______
Series of _______