PARENTAL/GUARDIAN CONSENT FORM FOR BSMT/BSMLS HOSPITAL INTERNSHIP TRAINING

MLSOJT1 Intern’s Name: ________________________________________

Home Address: ______________________________________________

I, _________________________________________, parent/legal guardian of the above intern,

expressly grant permission for my child/ward to undergo Medical Technology/Medical Laboratory

Science hospital internship training at ______________________________________________________

(Name and address of affiliation center assigned to)
for the period August 15, 2023 to February 14, 2024 and until his/her completion of all internship-1
(Internship period)
requirements and make-up duties.

As parent or legal guardian,

1. I understand that the honing of laboratory skills and community-related skills are best achieved in an
actual laboratory setting;
2. I am fully aware of the University of Baguio-School of Natural Sciences’ Policies, Procedures and
Guidelines (PPG) for hospital internship training as discussed during the pre-internship orientation;
3. I trust that the University of Baguio will make sure that the affiliation hospital (room/space,
manpower and patient/specimen-contact procedures) is compliant to CHED and DOH guidelines;
4. I know that the University of Baguio will take all reasonable care and necessary precautions to ensure
the maintenance of a safe and healthy laboratory environment; and
5. that I shall be one with the University of Baguio – School of Natural Sciences in monitoring my
child’s/ward’s academic progress, living condition and medical state.

I wish to be advised of my child’s/ward’s condition in the event of any emergency and/or health
problem while on clinical duty through this contact number/email address: __________________________

______________________________________
Name and Signature of Parent/Legal Guardian

*Please attach photocopy of a valid ID

Notary Public