AFFIDAVIT OF WAIVER

That I, _______________________________________, single/married, of legal age, Filipino

citizen, and a resident of ____________________________________________, after having been duly
sworn to in accordance with law depose and say:

That I am the father/mother of _________________________________ a student of Lyceum

Northern Luzon, College of _____________________________.

That as part of the School Curriculum my son/daughter will undergo a Field Training Exercise
on October 23- 26, 2013 in Regional Training School, Aringay, La union.

That in case of any accident or unusual incident that may happen or take place during his/her
training I will not claim any damage or benefit against the LYCEUM NORTHERN LUZON and REGIONAL
TRAINING SCHOOL.

That I hereby waive and renounce any and all rights and benefits that may arise from any
accident or unusual incident during his/her training.

That I am executing this affidavit to attest and confirm the truth, validity and legality of the
above facts.

IN WITNESS HEREOF, I have hereunto set my hands this _____ day of October, 2013 in the City
of Urdaneta, Pangasinan.

____________________________________
Affiant

Conforme:

__________________________________
Father/Mother

Subscribed and sworn to before me this _____ day of October, 2013 in the City of Urdaneta,
Pangasinan.

Doc. No. _________

Page No. _________
Book 106; ________
Series of 2013