PARENT/GUARDIAN CONSENT

This is to certify that I, _______________________, am the parent/guardian of

_____________________ , a Nursing student at Southwestern University- PHINMA, and I hereby grant
him/her permission to attend the Geriatric Nursing Field Trip on _____________ in St. Josephine
Vannini Home for the Aged Daughters of St. Camillus, Inc. Sitio Tigbao, San Jose Road, Talamban, Cebu
City.

The activity will be conducted in accordance with the health and safety protocols appropriate
for the activity and for the conditions at the time and as may be amended. SWU PHINMA has
implemented plans in place to reduce the risk of exposure to COVID-19, however, I recognize that none
of these plans and mitigation efforts can guarantee complete safety, nor eliminate all risks of exposure. I
am made aware that students participating will be required to follow these protocols and will be
immediately removed from the activity or program if they do not fully comply.

I am aware that health and safety protocols are being implemented by SWU PHINMA and
hereby agree that the below named student may participate in the activities and programs despite the
risks of exposure to COVID-19. I also certify that s/he on her/his free will, certified to me her/his decision
to participate as evidenced by her/his signature affixed below together with my own signature.

In view hereof, I hereby conform to hold SWU PHINMA, its officers, directors, managers,
employees and agents free and harmless from any liability for any injury, infection, death or any other
form of damage, I or my child may suffer, by reason of his/ her participation in the said event.

Name and Signature of Parent / Guardian: ________________________

Date Signed: ___________________

Name and Signature of Student: ________________________________

Date Signed: ___________________