Corner Leon Kilat & P.

del Rosario Streets, Cebu City, 6000, Philippines (032) 238-2380, (032) 238-2384 www.act.edu.ph asian_college@yahoo.com

PARENTAL CONSENT FORM

Parent/Guardian Contact Details

Name: __________________________________ Relationship to child:_______________________
Home address: ______________________________________________________________________
Telephone (home): ________________________ Mobile: _________________________________

Student Intern Contact Details

Complete Name: __________________________ Grade Level/Track:________________________
Class Adviser: ____________________________ Date of birth:_____________________________
Home Address:______________________________________________________________________
Telephone(home) ____________________ Mobile: _________________ Email: _____________

Does your child suffer from any medical conditions/allergies that the program should be aware of (including
any current medication)
______________________________________________________________________________________
______________________________________________________________________________________
Please provide details of the medication that must be administered:
______________________________________________________________________________________
______________________________________________________________________________________
Emergency contact details: (If different from above)
Name: ___________________________________________ Contact no: __________________________
Relationship to child: ____________________________________________________________________

I hereby certify that to the best of my knowledge and belief, the above statements are true and that the
minor named above may undergo the work immersion with my approval.

___________________________________________________ ____________
(Signature of Parent or Guardian and Relationship to Student Intern) (Date Signed)

AUTHORIZATION AND CERTIFICATION

I, __________________________________________ hereby state that I am the

(Full Name of Parent/Guardian)

____________________________ of _____________________________________, a bona fide student of

(Father/Mother/Guardian) (Student Intern’s Name)
Asian College of Technology International Educational Foundation.

I hereby consent and have been advised of the conditions and hours of the proposed work immersion of my
son/daughter being immersed during the 2nd semester of this academic year 2022-2023 specifically from
January to June in accordance with the information provided.

DATED this _____________________________.

__________________________________________________
(Signature of Parent or Guardian and Relationship to Student Intern)