INTRAMURAL CONSENT FORM

STUDENT’S INFORMATION
Full Name

Given Name Middle Initial Last Name Suffix

House Address

No Street Municipality/City Province

College Involvement State Event/s Participated
C ollege of Accountancy, Business and Entrepreneurship Organizer (if participant)
College of Computing and Information Sciences College Officer
College of Engineering Participant
College of Education, Arts, and Sciences Spectator
College of Health Sciences

Contact Number Age

TO THE PARENT/GUARDIAN:
please check one of the options below to confirm your permission or non-permission of your son’s/daughter’s attendance to the
activity

I am giving my full consent to my son/daughter to join the Intramural, which will be organized and facilitated by
the College Student Government on April 5-8, 2024. I attest that my son/daughter is in perfect health to
participate and has no underlying medical condition. I understand that the school is not an insurer of all risks and
eventualities. Hence, I hereby confirm that I have reminded my son/daughter to follow all the school rules and
activity regulations.

I am not permitting my son/daughter to join the Intramural activity.

PARENT’S/GUARDIAN’S UNDERTAKING
Relationship

Mother Father Others Please Specify:

Parent/Guardian Contact Number

(Printed name and Signature)
Date Signed

House Address of Parent/Guardian

No Street Municipality/City Province

STUDENT’S UNDERTAKING
I attest to the fact that I secured the permission of my parent/guardian, as evidenced by his/her signature.
Moreover, I confirm that all the information herein is correct and accurate to the best of my knowledge, and I
authorize the organizer to use with discretion the information contained herein as the organizer deems necessary
in view of my participation in this activity. I hereby attach my signature below to vouch for the veracity of the
above statements.

Student I.D. No

Course & Year

Student
(Printed name and Signature)
Date Signed
Note: All students, including the organizers, college officers, participants, and spectators, shall prepare and produce two (2) hard copies of the
Intramural Consent Form. A hard copy must be submitted to their respective Local Government Unit Officer and shall be forwarded to the Office
of the College Student Government for checking and verification.
 INTRAMURALPRACTICE CONSENT FORM
STUDENT’S INFORMATION
Full Name

Given Name Middle Initial Last Name Suffix

House Address

No Street Municipality/City Province

College Involvement State Event/s Participated
C ollege of Accountancy, Business and Entrepreneurship Organizer (if participant)
College of Computing and Information Sciences College Officer
College of Engineering Participant
College of Education, Arts, and Sciences Spectator
College of Health Sciences

Date/s and Address of Practices Contact Number

TO THE PARENT/GUARDIAN:
please check one of the options below to confirm your permission or non-permission of your son’s/daughter’s attendance to the
activity

I am giving my full consent to my son/daughter to join the Intramural, which will be organized and facilitated by
the College Student Government on April 5-8, 2024. I attest that my son/daughter is in perfect health to
participate and has no underlying medical condition. I understand that the school is not an insurer of all risks and
eventualities. Hence, I hereby confirm that I have reminded my son/daughter to follow all the school rules and
activity regulations.

I am not permitting my son/daughter to join the Intramural activities.

PARENT’S/GUARDIAN’S UNDERTAKING
Relationship

Mother Father Others Please Specify:

Parent/Guardian Contact Number

(Printed name and Signature)
Date Signed

House Address of Parent/Guardian

No Street Municipality/City Province

STUDENT’S UNDERTAKING
I attest to the fact that I secured the permission of my parent/guardian, as evidenced by his/her signature.
Moreover, I confirm that all the information herein is correct and accurate to the best of my knowledge, and I
authorize the organizer to use with discretion the information contained herein as the organizer deems necessary
in view of my participation in this activity. I hereby attach my signature below to vouch for the veracity of the
above statements.

Student I.D. No

Course & Year

Student
(Printed name and Signature)
Date Signed
Note: All students, including the organizers, college officers, participants, and spectators, shall prepare and produce two (2) hard copies of the
Intramural Consent Form. A hard copy must be submitted to their respective Local Government Unit Officer and shall be forwarded to the Office
of the College Student Government for checking and verification.
 ’23-‘24 INTRAMURAL ACTIVITIES
BACKLASH: Gearing Up the Cogs of Change
April 5-8, 2024

MEDICAL DECLARATION

Name:
College:
Contact Number:

o Mark (X) to indicate NO or YES to each question. Do not leave any blank.
o If you mark YES, please CHECK the specific medical condition & provide details
No. Does the participant suffer from, experience or have NO YES Details of Condition (e.g. date last occurred,
any history of the following medical conditions? (X) (X) severity; prescribed medication – dosage &
(please MARK CHECK ABOVE THE LINE & specify) intake schedule)
1 Seizures Headache Epilepsy
Fainting Migraine

2 Dizziness Chest Pain Unusual

shortness of breath while walking or exercising

3 Heart Disease Palpitations

Heart Murmur

4 High Blood Pressure (Hypertension)

Stroke Diabetes (Insulin
Dependent/Non-Insulin Dependent)
5 Allergy to:
Medicines
Foods and others/medication reactions
(please specify)
6 Routine or current maintenance medications AM –
(please specify: dosage, schedule of intake) NN –
PM –
7 Medical treatment of hospitalization within the
last two years
8 Bone or join injuries and other Orthopedic
conditions (temporary/permanent): e.g.
fractures/dislocation, sprains/strains
9 Any problems in the following areas:
Neck Clavicle Shoulders
Hips Knees Back
Wrist Ankles
Others:

10 Did you have the following signs and symptoms

within the last 14 days?
Fever Cough Runny Nose
Sore Throat Shortness of Breath

11 Fully Vaccinated for COVID - 19 First Dose Date:

Second Dose Date:
Booster Shot Date:
Vaccination Card ID Number:

I hereby certify that, to the best of my knowledge, my answers to the above questions are complete and correct.
Signature of participant:
Person to Contact in Case Emergency:
Contact No.: