B i c o l

U n i v e r s i t y

Legazpi City, Philippines

Parents /Guardians Permit Form

_____ semester, SY ______________

PLEASE TAKE NOTE CAREFULLY

1. Please fill up this form in BLOCK LETTERS.
2. ALL sections MUST BE COMPLETED when applicable.
3. Permit should be duly NOTARIZED for Educational Tour/Field Trip purposes and when participant is a minor.

TO WHOM THIS MAY CONCERN

This certifies that ____________________________________________, a ________________
(Course and Year)

of the College of ____________________________________ with Student No. ___________________

has the permission of his/her undersigned parent(s)/guardian(s) to participate and/or attend in the
______________________________________________________ on ________________, 20 _____
in _______________________.
This certifies further that risk assessment plans and necessary safety and precautionary
measures have been instituted.
Further, that the following faculty members shall accompany him/her in the travel.
1. ___________________________________

_____________________________

2. ___________________________________

_____________________________

3. ___________________________________

_____________________________

4. ___________________________________

_____________________________

Faculty Name (Please print)

Faculty Signature

Faculty Name (Please print)

Faculty Signature

Faculty Signature

Faculty Name (Please print)

Faculty Signature

Faculty Name (Please print)

Note: If the student is a minor, both parents MUST sign the permission form.
I/We have honestly and accurately completed all parts of the Parents/Guardians
Permit Form to the best of my/our ability.
_________________________________

_________________________________

_________________________________

_________________________________

Parent/Guardian Signature #1

Date

Parent/Guardian Signature #2

Parent/Guardian Name (please print)

Date

Parent/Guardian Name (please print)

_________________________________

_________________________________

_________________________________

_________________________________

Complete Address
Contact Numbers

Complete Address
Contact Numbers

JURAT
On ________, of 20 ___, before me personally appeared, ______________________________
and ___________________________________ to me known to be the individual, or individuals
described in and who executed the within and foregoing instrument, and acknowledged that
he/she/they signed their free and voluntary act and deed, for the uses and purposes therein
mentioned.
Given under my hand and official seal this ______ day of _________________, 20 ____.

Notary Signature: __________________________

Notary Printed Name : ____________________________

Affix seal
here

My commission expires: ___________________________

BU OSS

Office of Student Services

Student Activities Section

S A S

BU-F-OSS-34

Effectivity: September 13, 2012

Revision No. 1

P. 1 of 1