OFFICE OF STUDENT AFFAIRS

WAIVER AND RELEASE OF LIABILITY

In consideration of my use of the _____________________DORMITORY for ___ semester, SY ___________
I, _____________________________________, of legal age, single/married, with address at
_______________________, individually, and together with my parent(s)/guardian(s)

Name Address
Father: ________________________ ________________________________
Mother: ________________________ ________________________________
Guardian: ________________________ ________________________________
(collectively, “Users”), for myself/ourselves, my/our heirs, executors, administrators and assigns depose and
state that:

(FOR PARENTS WHO REQUEST THAT THEIR CHILD BE ACCOMMODATED IN CAMPUS DORMITORY
HOUSING DURING THE COVID-19 PANDEMIC)

1.I am the parent of __________________________________, a student of Central Mindanao University;

2. I acknowledge that classes in Central Mindanao University for the ___semester of school year ________,
and for periods that may be hereafter announced, will be held face to face or through blended/flexible means
as a way of mitigating the effects of Covid-19;

3. Notwithstanding the foregoing fact, I have requested Central Mindanao University to accommodate my
child in a campus residential unit/dormitory for the duration of ___semester of school year ________;

4. I recognize that Central Mindanao University has Covid-19 protocols that apply to all its personnel, students
and campus residents;

5. I agree that my child shall be bound by such protocols, including regulated/limited access to off-campus
areas;

6. Despite the existence of such protocols, I am aware that my child is not impervious to Covid-19 exposure;

7. Consequently, I agree that I am personally responsible for the safety and actions of my aforenamed child
while he/she is staying in Central Mindanao University;

8. With full awareness and appreciation of the risks faced by my child while he/she is residing in a place not
his/her home during a pandemic, I, for myself and on behalf of my family, spouse, estate, heirs, executors,
administrators, assigns, and personal representatives, hereby forever release, waive, discharge, and
covenant not to sue Central Mindanao University, its board members, officers, employees, successors, and
assigns from any and all liability, claims, demands, actions, and causes of action whatsoever, directly or
indirectly arising out of or related to any loss, damage, or injury, including death, that may be sustained by my
child arising from Covid-19 in course of his stay and study in Central Mindanao University;

9. I further agree to indemnify, defend, and hold harmless Central Mindanao University from and against any
and all costs, expenses, damages, claims, lawsuits, judgments, losses, and/or liabilities (including attorney’s
fees) arising either directly or indirectly from or related to any and all claims due to bodily injury, death, loss of
use, monetary loss, or any other injury related to Covid-19;

10. By signing below I acknowledge and represent that I have read the foregoing Waiver of Liability,
understand it and sign it voluntarily as my own free act and deed, including without limitation the Release of
Liability and Indemnification requirements contained in this document;

11. I am at least eighteen (18) years of age and fully competent; and I execute this document for full,
adequate, and complete consideration fully intending to be bound by the same;

12. I agree that this Wavier of Liability shall be governed by and construed in accordance with Philippine law
and that if any of the provisions hereof are found to be unenforceable, the remainder shall be enforced as fully
as possible and the unenforceable provision(s) shall be deemed modified to the limited extent required to
permit enforcement of the Wavier of Liability as a whole;

13. It is understood that this Waiver and Release of Liability shall not be construed as an admission of liability
by Central Mindanao University, and that any such admission is hereby expressly denied;

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OFFICE OF STUDENT AFFAIRS

(FOR STUDENTS WITH VALUABLES SUCH AS LAPTOPS, BICYCLE, MOTORCYCLE AND THE LIKE)

14. My use of the Dormitory is voluntary and carrying of valuables was undertaken at my/our own risk;
 Motor - Model : ______ Plate Number:________  Laptop – Brand:_________
 Bicycle - Model : ______ Plate Number:________  Others ________________

15. WAIVE AND RELEASE ____________Dormitory, Office of Student Affairs and Central Mindanao
University, (the “Released Party”), any and all claims for loss of property or damage I/we may have, or that
may subsequently accrue to me/us, or to my/our heirs, executors, administrators or assigns, as a result of, or
in any way related to my/our use of the Dormitory;

16. DISCHARGE AND RELEASE in advance ___________Dormitory, Office of Student Affairs and Central
Mindanao University, (the “Released Party”), and its respective officers, directors, shareholders, agents,
representatives, parents, subsidiaries and employees from any and all liability, claims, demands, damages,
debts, liabilities, causes of action, losses, costs expenses or any other loss whatsoever (collectively, “Claims”)
arising out of or connected in any way with my/our use of the Dormitory, though that liability may arise from
alleged negligence or carelessness on the part of the Released Party;

17. INDEMNIFY Released Party and hold the Released Party harmless from and against any and all Claims
arising out of or connected in any way with the use of the Dormitory, whether such Claims are incurred or
suffered by me/us or any of my/our agents, invitees, users, participants or guests in connection with the
Dormitory or any resident, invitee or guest of Released Party;

18. I/we fully understand that using the Dormitory involves risks and dangers of loss and damage to my
property which may be caused by my/our own actions or inactions, those of others (whether using the
Dormitory or not), weather, and other conditions, and I/we hereby willingly accept and assume all risks and
accept full responsibility for any and all loss, damage that may be sustained while using the Dormitory;

(FOR AUTHORITY TO DORM MANAGER’S ISSUANCE OF PERMIT ON ALLOWED ACTIVITIES)

19. Authorize the dormitory manager to issue a permit to my daughter/son and allow the following activities
outside the dormitory premises within ____Semester, SY ________________:

Group study Organizational Activities

Practice Others (activities not included in the list, parents/guardian
Religious must call or text the Dormitory Manager for approval)
Co-curricular Activities

20. The validity of this authority, waiver, and release of liability is within the covered semester.

21. In case of any untoward incident when our child is permitted by the dorm manager as enumerated above,
we assume full responsibility and accountability, and therefore we hereby release and discharge and by this
presence our heirs, successors, and assigns release and forever discharge the dormitory manager, the CMU,
its officers from any and all causes of action of whatever nature.

WE HEREBY DECLARE THAT WE HAVE FULLY READ AND FULLY UNDERSTAND EVERYTHING
WRITTEN ABOVE AND WE VOLUNTARILY SIGN THIS WAIVER AND RELEASE OF LIABILITY. WE
FURTHER UNDERSTAND THAT BY SIGNING THIS WAIVER AND RELEASE WE ARE WAIVING
VALUABLE LEGAL RIGHTS, INCLUDING, BUT NOT LIMITED TO, ANY CLAIMS ARISING FROM ANY
NEGLIGENT ACT OR OMISSION OF THE RELEASED PARTY.

SIGNED ON the date and place stated below.

ID Number Place of Issue
________________________________ ____________ _________________
(Student Signature over printed name)

________________________________ ____________ _________________

(Mother Signature over printed name)

________________________________ ____________ _________________

(Father Signature over printed name)

________________________________ ____________ _________________

(Guardian Signature over printed name)
CMU-F-1-OSA-001 03June2019 Rev.0 Page 1 of 3
OFFICE OF STUDENT AFFAIRS

Signed in the presence of:

_____________________________ _____________________________

ACKNOWLEDGMENT
Republic of the Philippines
Municipality of Maramag

BEFORE ME, a Notary Public for and in the __________, this ___________________, personally
appeared the aforenamed persons known to me and to me known to be the same persons who executed the
foregoing Waiver and Release of Liability consisting of two (2) pages including the page on which this
Acknowledgment is written, and who acknowledged to me that the same is their free and voluntary act and
deed.

IN WITNESS WHEREOF, I have placed my hand and seal on the date and at the place first above-
written.

CMU-F-1-OSA-001 03June2019 Rev.0 Page 1 of 3