LOCAL OFF-CAMPUS ACTIVITIES

CERTIFICATE OF COMPLIANCE

This is to certify that all the processes, procedure and requirements before the conduct of the off-
campus activity/ies pursuant to CMO No. 63, s. 2017 entitled “Policies and Guidelines on Local Off-
campus Activities” have been duly complied with, and that by the virtue thereof, we hereby assume full
responsibility for the safety and welfare of the students.

Certified Correct: Recommending approval:

JELLY MAE B. LONGALONG _______RB J. GALLEGO Ph. D_____

Personnel-in-Charge Vice-President for Academic Affairs

Approved by:

EUTIQUIO L. ROTAQUIO Jr., PhD

President/Head of HEI/
Authorized representative

SUBSCRIBED AND SWORN to before me, this __________________ by _______________ who

Exhibited to me(his/her) competent proof of identification _________________________issued at
____________________, Philippines on _____________________,

Notary Public

Doc. No. _______________;

Page No. ______________;
Book No. ______________;
Series of _______________;
 LOCAL OFF – CAMPUS ACTIVITY FORM

REPORT OF COMPLIANCE
Before the Off – Campus Activity
(Following CHED CMO No. 63 Series of 2017)
2022-2023

NAME OF HEI: AURORA STATE COLLEGE OF TECHNOLOGY REGION: III_____

ADDRESS: Brgy. Zabali Baler, Aurora______________________

BASIC INFORMATION

PROGRAM COURSE DESTINATION/S INCLUSIVE NUMBER OF LIST OF

NAME AND VENUE DATES STUDENTS PERSONNEL-IN-
CHARGE
Immersion II AT 10 Annies June 2023- 4 JELLY MAE B.
MotorCycle July 2023 LONGALONG
parts & repair
shop
REPORT BEFORE THE ACTIVITY:

ACTIVITIES COMPLIANCE
YES/NO REMARKS
1. Curriculum Requirements Yes BOT Resolution No. 23 Series of
2018
2. Destination Yes Annies Motor Cycle parts & repair
shop
3. Handbook or Manual Yes External and internationalization
manual
4. Students’ Consent of the Parents/Guardians Yes Completed
Medical Clearance of the Students
5. Personnel – in – Charge Yes Jelly Mae B. Longalong
6. First Aid Kit Yes First Aid Kits will be available
7. Fees/ Funds No None
8. Insurance Yes Redcross Baler
9. Mobility of Students (Vehicles) Owned by the No
HEI, Third Party or Subcontracting
franchisee/Travel Agency/Tour Operator
10. LGU’s/ NGO’s Yes Annies MotorCycle parts & repair shop
11. Activities Yes Attached document
Orientation to students
Consultation
Announcements
Briefing before the trip
Learning Journals
Emergency Preparedness Plan
Syllabus
Certified Correct: Recommending approval:

JELLY MAE B. LONGALONG _______RB J. GALLEGO Ph. D_____

Personnel–in–Charge Vice President for Academic Affairs

Reviewed by: Approved by:

MARK ANTHONY M. DOCTORA, RME. EUTIQUIO L. ROTAQUIO Jr., PhD

Dean of Program Head President/Head of HEI/ Authorized representative