REPUBLIC OF THE PHILIPPINES )

) s.s.

INTERNSHIP / ON-THE-JOB TRAINING

WAIVER AND PERMISSION FORM
I, , of legal age, Filipino citizen,
(Full Name of Student)
( ) single / ( ) married, and a resident of ,
(Please check) (Complete Residential Address)
after having been duly sworn to in accordance with law, do hereby depose and state that:

1. I am student at the Mindoro State

(Year and Degree/Course)
University (MinSU) – ;
(Campus)
2. In partial fulfillment of the requirements for my degree, I shall be undergoing an internship
/ on-the-job training of
(Name of Host Training Establishment)
at
(Address of Host Training Establishment / Training Site)
starting from until for a total of hours;
(Covered Dates of Training) (Hours of Training)

3. In relation to the said training, I hereby declare and undertake the following:
a. I shall take the necessary precautions to avoid or get involved in any incident that may
cause loss, damage or injury to my own person and property or that of another;
b. I shall be held liable for any loss, damage or injury that is attributed to my own
negligence;
c. I hereby declare that I am healthy, fit, or free from any medical condition that may be
aggravated by my participation in such training. Otherwise, I commit to immediately
report my medical condition in writing to the assigned faculty/SIPP/OJT coordinator to
excuse myself from the said training and request for an alternative;
d. I hereby declare that I understand and shall strictly observe the host training
establishment’s (HTE) / partner institution’s and MinSU’s rules on security and
confidentiality of business information and other regulations that may be implemented by
my direct supervisor and our faculty/SIPP/OJT coordinator in relation to such training;
e. I have properly informed my parents or guardian of the nature of the training that I am
joining and had secured their consent for my participation in the same. I likewise secured
their advice on the measures which I am to undertake for my personal safety and security;
and
f. I hereby waive any responsibility on the part of MinSU in relation to any untoward
incident which may happen to me during the said training unless such untoward incident
arose from the direct act and gross negligence of MinSU.

IN WITNESS WHEREOF, I hereby affix my signature this day of

in .

Signature over Printed Name of Student Contact No. of Student

Identification Card of Student

Name of Father Contact No.

Name of Mother Contact No.

Name of Guardian Contact No.

Internship / OJT Training Waiver and Permission Form I Page 1 of 2

REPUBLIC OF THE PHILIPPINES )
) s.s.

This is to certify under oath that I am permitting my child/ward:

(Full Name of Student/Child/Ward)

to undergo his/her internship / on-the-job training particularly identified in page one (1) of this document.

I have read page 1 of this document which is duly signed by my child/ward and declare my
conformity to all provisions stated therein.

Further, I hereby undertake the following:

a. I will be solidary liable with my child/ward for any loss, damage or injury that is attributed to my
child’s/ward’s own negligence; and

b. I hereby waive any responsibility on the part of MinSU in relation to any untoward incident
which may happen to my child/ward during the said training unless such untoward incident arose
from the direct act and gross negligence of MinSU.

IN WITNESS WHEREOF, I hereby affix my signature this

in .

Signature over Printed Name of Parent/ Guardian

Identification Card of Parent/ Guardian

SUBSCRIBED AND SWORN to before me this day of

in .

Doc. No. ; Page

No. ; Book No. NOTARY PUBLIC
; Series of .

Internship / OJT Training Waiver and Permission Form I Page 2 of 2