OSAS-QF-25

Republic of the Philippines

CAVITE STATE UNIVERSITY
Don Severino delas Alas Campus
Indang, Cavite

STUDENT INFORMATION

Flores Rica Mae F.

Last Name First Name M.I Sex 0 8 2 1 0 3
Date of Birth
(mm/dd/yyyy)

336 Crisanto M. Delos Reyes St. Manggahan Gen. Trias Cavite

2 0 2 2 0 1 8 5 2
Mailing Address Student Number

Contact Number: 09533449927 Academic

Non-Academic
Name of Organization CvSU Otaku Society Performing Arts
Group

Name of Adviser/s in charge: Gierone Lianni Reyes and Poinsettia Vida

PARENT/GUARDIAN PERMIT/CONSENT

This is to certify that I have full knowledge of and permission for my son/daughter/foster
child to join and participate in:

Title of Activity: CvSU Otaku Society First General Assembly and Mini Christmas Party

Date & Time of the Activity: December 16, 2023 1:00-5:00 pm

Place of Activity: Department of BioSci Lecture room

I concur and agree on the rules, policies & regulations being implemented by the concerned
organizers.

Eduard M. Flores 09125541606

Name & Signature of Parent/Guardian Contact Number

Subscribed & sworn to me this 12th day of December 2023 at 336 Crisanto M. Delos Reyes St.
Manggahan GTC

V01-2018-05-28