POLYTECHNIC UNIVERSITY OF THE PHILIPPINES

San Pedro Campus

Bgy. United Bayaniham, San Pedro, Laguna
FIELD STUDY 5 WAIVER OF LIABILITIES

The Polytechnic University of the Philippines San Pedro Campus with postal address at Brgy.
United Bayanihan, San Pedro, Laguna, hereby agrees to endorse Felicia Veronica Manalili Bondad to
undergo her required hours of observation in EDUC 2161 Field Study 5 Learning Assessment Strategies
which is an academic requirement on her degree, under the following terms and conditions:

1. That she shall abide the school's rule and requisition and shall comply with those imposed for the
programs; otherwise she shall be excluded from further participation.
2. That PUP San Pedro Campus and the school where she will be placed shall not in any way be held liable
for any accident or injury that she may suffer in the course of her training visit.
3. That she should be made answerable in any and all liabilities for damage to property or injury to third
persons, which may be occasioned by her intentional or negligent acts as while in the course of her training.

Signed this ___ day of __________, 2014 at Polytechnic University of the Philippines, San Pedro
Campus. I hereby waive/renounce the right to any claim for compensation or course of action against
PUP San Pedro in any case of accident/injury during the duration of the training.


Felicia Veronica Manalili Bondad
Name of Student

Witness:

__________________________________ ________________________________
FSS/ST Coordinator Trainers Name and Position


PARENTAL CONSENT FORM

I, Demetria M. Culala, of legal age and a resident of Blk 5 Lot 10 Amber St. Pacita 2B Brgy. San Vicente San
Pedro, Laguna, hereby authorize the Polytechnic University of the Philippines-San Pedro Campus, to send Felicia
Veronica Manalili Bondad for the Field Study 5/Observation for (__17__) hours.

I hereby waive/renounce the right to any complaint for compensation or course of action against PUP San
Pedro and Sampaguita National High School Southville 3A Extension in any case of any accident/injury in the course
of the Field Study 5/Observation.

In view of the foregoing, I hereby affixed my signature below this ___ day of July, 2014 at San Pedro,
Laguna.

_________________________
Affiant
JURAT

SUBCRIBED AND SWORN to before me this ___ day of ________, 2014, affiant exhibiting to me his/her
government issued Identification Card No. _______________ issued by________________________ with expiry
date on _________________. (Name of Government Agency)

WITNESS MY HAND AND SEAL on the day first above written.


NOTARY PUBLIC
Doc No.______;
Page No._____;
Book No._____;
Series of 2014