Republic of the Philippines AURORA STATE COLLEGE OF TECHNOLOGY Brgy. Zabali, 3200 Baler, Aurora, Philippines ‘Sir/Ma’am: ‘This is to allow my child | Won Lance/ J. ean fata BWE 2-0 2)-1-1937 Nam of Ci Cour Year ID Naber to attend/join/participate in the activity/competition mentioned below: Tile of the Activin’: — nee pasneal Baeineco'ng Dacy aurel bra lil Ct tule OF, P22 BAT Date of the Activity ‘Venue of the Activity: Please be informed of the following health-related conditions of my child/ward namely (leave blank if none) Further, [expect the Aurora State College of Technology through thei.q/CCHAG Departmrnt — oftice, who hereby confirms that s/he is truly aware of his/her obligation as such, to ensure the safety and security of my child. However, I will not hold the Aurora State College of Technology andor *g/ncering hepato] ostice liable for any untoward incident that may happen beyond their control ‘© The guardian should atleast be 21 years-old and is a person related to the childiward by affinity or consanguinity or by being appointed by the parents to take care of thei child Date Signed: Gey 1G) 707% ‘* Siblings less than 21 years old cannot act as lamthe: Parent _ Guardian guardian ofthe childiward 04200107430 + Unsigned waivers as well as waivers submittedlate Comet Number: PTCA TT 2120 _ shall mean that the childiward is not allowed to attendjoin the activity. ‘+ Forging of signatures is not allowed and is subject to disciplinary sanctions Sign above Pinte Name of Perse Charge SUBSCRIBED AND SWORN TO before me this at by affiantdeclarant who presented to me a competent evidence of his/her identity as indicated below his/her name. Doe. No. _ | Page No. | | Book No. | Sees offa tm