PARENT’S WRITTEN CONSENT

I/we the undersigned parent/s of ________________________________

execute this written consent and express permission for our daughter/son to
participate in the ___________________________to be held at
______________________________ from _____________________ to
_______________________.
We understand that the internship program is a requirement for the
completion of the degree _________ and that we have been oriented of the policies,
guidelines and requirements as well as the possibility of risk that may be caused by
any untoward incident.
We assume that all the responsible officials for the internship program will
take precautionary measure for the safety and welfare of my son/daughter. As such
I/we will not hold the _________(Department/College)_____, the Eastern Samar
State University and the ______(Name of HTE) liable for any untoward incident
that may happen during the activity that is beyond the control of the adviser.
With our parental consent and our high regard for the institution, I/we hereby
affix our signature/s below this _____ day of ________________________,
__________.

__________________________ __________________________
Name and Signature of Father/Guardian Name and Signature of Mother/Guardian

ACKNOWLEDGEMENT

BEFORE ME, a Notary Public for and in the _____________________

personally appeared the following persons who presented to me their competent
proof of identities as follows:

Name Proof of Identity Issued at / Valid until

known to me to be the same persons who executed the foregoing Agreement and
acknowledge to me that the same is their free and voluntary act and deed and that of
the institutions they respectively represent.

This instrument referred to as Parents’ Written Consent consisting of two

pages, including this page whereon this Acknowledgement is written and signed by
the parties and their instrumental witnesses.

WITNESS MY HAND AND NOTARIAL SEAL, at the date and place first
mentioned.

Doc. No. ___;

Page No. ___;
Book No. ___;

ESSU-ODIP-104 | Version1 Page 1 of 2

Effectivity Date: December 2, 2021
Series of 2018.

ESSU-ODIP-104 | Version1 Page 2 of 2

Effectivity Date: December 2, 2021