Control No.

2022-003

Parent Approval / Release Form

Student's Name: Ma. Hannah Carmela G. Garcia Program & Section: HUMSS 221
Activity Date: September 18, 2023 Title of Activity: LENTE FILM AWARDING

I, the undersigned parent / guardian of Ma. Hannah Carmela G. Garcia do hereby authorize my
daughter to participate in the said activity. I understand that during this campus activity, my daughter
will be under the direction and general supervision of the Senior High School (college / department) and
university personnel selected by the university, and that my daughter is subject to discipline for her
conduct during the activity.

MEDICAL RELEASE

In the event my daughter / son needs medical attention during the LENTE FILM AWARDING, I hereby
give my permission to the Senior High School (college / dept.) representatives to take my daughter to
a physician, hospital, or other medical institution for treatment. I expressly authorize all medical
treatment which a physician may determine necessary under the circumstances and understand that it
may not be feasible to contact me prior to the provision of medical treatment to my child. I understand
and agree that I, and or my daughter / son other parent(s) legal guardian(s), am responsible for all
medical expenses incurred in treating my daughter / son unless it is related injury and that
time Senior High School (college / dept.) representatives for off – campus activity Senior High
School are not responsible for such expenses.

In addition, I authorize the Senior High School (college / dept.)

representatives to administer / dispense the prescription and / or non – prescription medication
indicated on this form to my child as appropriate, I understand that I must complete this form and
provide to school representatives any medications indicated on this form to my daughter / son as
appropriate, I understand that I must complete this form and provide to school representatives any
medications. I want administered / dispensed to my daughter / son during the LENTE FILM
AWARDING for such medications to be administered / dispensed.

Medical condition(s) (including allergies) that may affect student during campus activity:

MEDICATIONS: List any medications that the student take while on the off – campus activity, the
instruction for administrator of each medication, and the medical condition for which the medication is
needed.

Medication Instruction Medical Condition

n/a n/a n/a

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 Control No.2022-003

Parent Approval / Release Form

Custodian Parent / Guardian Name: Patricia Valerie G. Garcia

Home Phone: _ n/a Cellphone: 0966-764-0703

Name of Emergency Contact (in case I cannot be reached): Edgardo G. Garcia

Phone # (s): 0935-168-2373

Health Insurance Co. n/a Policy: n/a

Dated this 26th day of August 20 23

Parent / Guardian Name (please print): Patricia Valerie G. Garcia

Parent / Guardian Signature:

PLEASE ATTACH PHOTOCOPY OF PARENT/GUARDIAN IDENTIFICATION CARD WITH 3

SPECIMEN SIGNATURE.

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