DEAN OF STUDENTS OFFICE

Visca, Baybay City, Leyte, PHILIPPINES

Tel No.: 053 565 0600 (loc 1070)
Telefax: +63 53 563 7067
Email: usso@vsu.edu.ph
Website: www.vsu.edu.ph

PARENTAL CONSENT FORM

Permission is granted for my/our son/daughter to participate in the NuCM 109r Duty

NAME OF STUDENT :
COURSE and YEAR : BSN 2
SCHOOL : Visayas State University
SUBJECT : NuCM 109r
DESTINATION : Immaculate Conception Hospital (Baybay City), Baybay Family Care
And Maternity Clinic, St. Anne Birthing Clinic (Ormoc City)
DATE : February 8 – April 20, 2024

I/We hereby acknowledge that sufficient information has been provided by the school with respect
to the planned activity, duration, location, method of transportation, participants and supervision.

I/We hereby acknowledge that certain RISKS or INJURIES are inherent to participate in learning
activities outside the school. These types of injuries may be minor or serious and may result from one’s
actions, or the actions or actions or inaction of others, or a combination of both.

I/We understand that the rules and regulations established for this off-campus activity are designed
for the safety and protection of the participants and hereby undertake to inform my child to abide these
rules and regulations.

I/We declare having read and understood the above Parental Consent Agreement in its entirety and
hereby consent to allow my/our child to participate, acknowledging all of the foregoing.

IN WITNESS WHEREOF, I/We hereto affix my/our signature this _____th day of ___________,
2024 at ________________________ Leyte, Philippines.

____________________________
Parent/Guardian Parent/Guardian
(Signature over printed name) (Signature over printed name)

Valid ID No. Valid ID No.

SUBSCRIBED AND SWORN to before me this ____th day of _____________, 20___

at______________________________________________________, Philippines

Notary Public
Doc. No. ________
Page No.________
Book No.________

Must be accomplished in six (6) copies

Page 1 of 1
Vision: A globally competitive university for science, technology, and environmental conservation.
FM-ODS-29
Mission: Development of a highly competitive human resource, cutting-edge scientific knowledge and innovative v0 02-11-2022
technologies for sustainable communities and environment.
No.