ST.

ALEXIUS COLLEGE
Gen. San. Drive, City of Koronadal, Sout Cotabato, Philippines 09506, Tel.: (083) 228-2019, Fax: (083) 228-4015, Email: st.alexiuscollege@yahoo.com

COLLEGE OF NURSING

WAIVER OF RIGHTS

TO WHOM IT MAY CONCERN:

This is to certify that I, __________________________________ parent/guardian of

______________________________, a Bachelor of Science in Nursing ____________ student of
(Student Name) (Year Level)
St. Alexius College, City of Koronadal, granted him/her permission to undergo the Bachelor of Science in
Nursing Related Learning Experience at the _______________, __________________,
(Area of Duty) (Affiliating Institution)
__________________, from __________ to ___________, _____. I understand and agree that this
(Location) (Training Period)
training is a partial requirement of his/her Bachelor of Science in Nursing degree program.

I further affirm that _______________________________ is no way responsible nor shall

(Name of Affiliating Institution)
pay any compensation for any accident, harm, infection or injury that may be caused on his/her person during
the training except for the accident insurance covered as a student of St. Alexius College and that this student
will undergo the said actual field training and she/he cannot demand any compensation from either St. Alexius
College and the Training/Affiliating Institution (________________________).
(Affiliating Institution)

I also certify that he/she has on his/her own free-will signified to me his/her decision to undergo this Related
Learning Experience exposure as evidenced by his/her signature affixed below together with my own signature.

Signed and issued this _____day of ____________, __________ St. Alexius College, General Santos Drive,
Zone IV, City of Koronadal.

_________________________ ____________________________
(Student-Trainee) Parent/Guardian
(Signature over Printed Name) (Signature over Printed Name)

WITNESSES:

ARIES M. BALDONADO, RN, RM, PhD, LPT

Level Coordinator – Nursing Dean – College of Nursing

JOHN THOMAS C. FRANCO, RN, MAN, PhD

Executive Vice-President