New Era University

No. 9 Central Avenue, New Era, Quezon City

Integrated School
___________________
Department

Date: _______________

Dear Sir/Madam:

The undersigned wishes to inform you that your child/ward _____________________________

Name of Student
December 7, 2023 , 8:00am to 12:30pm
together with his/her classmates will undertake an off-campus activity on _________________________
Date
Philippine Nuclear Research Institute, Commonwealth Ave. Quezon City to participate in the
at ________________________________________. The purpose of this activity is ________________
Location
Annual Celebration of Atomic Energy Week.
_____________________________________________________________________________________

In view of this, we wish to obtain your consent for him/her to join this activity by signing the
waiver below.

Thank you.

Truly yours,

_________________________
Teacher/Instructor
____________________________________________________________________________________

CONSENT

We/I, __________________________________________________, parents/guardians of

Name of parent/guardian

 Integrated School  College Student, ________________________, Year & Section ______________

Name of Student

Hereby affix our signature as a proof of our/my consent to our/my child’s joining the

__________________________________________ in ________________________________________
Activity Location

We/ I hereby hold free and harmless New Era University, ____________________ and any of its
officers, teachers and staff in the event of any accident, injury, sickness that may befall our/my child in
the course of this activity knowing that the school shall and will exercise extraordinary diligence.
Signed this ____ of ____________, ____________ in _________________________________
Day Month Year Place

_______________________ ____________________________
Relation Signature over printed name
__________________________________________________________________________________

SUBSCRIBED AND SWORN to before me, this ____________, by ____________ who exhibited to me
(his/her) competent proof of identification _____________________ issued at ____________________,
Philippines on ______________________.

Notary Public

Doc. No. ____________;

Page No. ____________;
Book No. ___________;
Series of ____________;