PHILIPPINE CENTRAL ISLANDS COLLEGE

Bagong Silang, San Jose, Occidental Mindoro 5100

Website: www.mindoro.esti.edu.ph Telefax No.: (043) 457-0140
SENIOR HIGH SCHOOL DEPARTMENT

WAIVER AND PERMISSION FORM

Student’s Name
This is to certify that I am permitting my son/daughter, ____________________, a
Year &Section
student of _________________ to conduct an interview at
School’s Name/Location/Address
________________________________________________________________to the study
Research Title
entitled _______________________________________________________________________,
in partial fulfillment of the requirements for the subject Practical Research 1.

My son/daughter understands that s/he should strictly observe the rules and regulations of
School/Location/Address
_____________________________________ and Philippine Central Islands College in relation
solely to the mentioned activity.

I hereby agree to waive any responsibility to whatever trouble that may happen to my
son/daughter during the said process.
School’s Name/Location/Address
I also hereby agree to hold render ________________________________ free and
harmless, including its officers, employees, or staffs, from any liability, suit or claim filed or
made by any part for any risk or damage to property that my son/daughter may cause to his/her
willful acts, fault or negligence, whether or not the same arises from or is related to his/her
proceedings of the study.

__________________ _____________________ ____________________

Name of Father Signature Date

__________________ _____________________ ____________________

Name of Mother Signature Date

__________________ _____________________ ____________________

Name of Student Signature Date