CENTRAL PHILIPPINES STATE UNIVERSITY

Kabankalan City, Negros Occidental

OJT/PRACTICUM/INTERNSHIP PROGRAM

STUDENT WAIVER AND RELEASE AGREEMENT

In consideration of my enrolment in the course Bachelor of Science in Agriculture (BSA) –

OJT (OJT/Practicum/Internship) subject, myself, my heirs, executors, administrators and assigns,
do hereby release and discharge the Central Philippines State University (CPSU), Kabankalan
City, Negros Occidental, and other concerned parties, group or individuals, from all claims and
damages, demands or actions in any manner whatsoever arising from or within the place I am to
conduct my OJT/Practicum/Internship. I further agree to abide by the rules and regulations
imposed by __________________________________ on all its employees. I further attest and
verify that I have fulfilled all pre-requisites imposed by CPSU prior to the conduct of my
OJT/Practicum/Internship and that I have full knowledge of the risks involved in conducting the
OJT/Practicum/Internship outside the CPSU campus.

PARENT’S/GUARDIAN’S CONSENT

This is to certify that I have full knowledge of and permission for my son/daughter to
conduct his/her OJT/Practicum/Internship outside the CPSU campus. I conform and agree to all
the rules, regulations and measures imposed by all concerned parties.

_____________________________ ______________________________
Student Parent
(Signature over printed name) (Signature over printed name)

_____________________________ ______________________________
Date Signed Date Signed

----------------------------------------------------------------------------------------------------------------------------------

SUBSCRIBED AND SWORN before me this day of by

who exhibited to me his/her CTC No. issued on at
.

Notary Public

Doc. No. ;
Page No. ;
Book No. ;
Series of ;

Doc Control Code:CPSU-F-OJT-01 Effective Date:06/20/2019 Page No.:1 of 1