PARENT/GUARDIAN CONSENT FORM

(for OFF-CAMPUS ACTIVITIES)

Submission Date

Name of Student ID Number

Activity Academic Non-academic Self-initiated (not DLSU sanctioned)

Title of Activity

Nature/Description

Date and Time of Activity Place/Venue of Activity

Departure Date and Time Arrival Date and Time

FOR UNIVERSITY SANCTIONED ACTIVITIES:

Office/Student Organization Landline

Mobile
Faculty/Staff-in-Charge or
Supervising Personnel ________________________________ Email Address
Signature over printed name (@dlsu.edu.ph)

Mobile
Dean/Director/Chair/Unit Head
________________________________ Email Address
Signature over printed name (@dlsu.edu.ph)

PARENT/GUARDIAN UNDERTAKING:
1. I consent and allow my child/ward to join the activity described above;
2. I understand that the University and its officers, faculty, and staff are expected to exercise the legal diligence required for the
safety and well-being of my child/ward for the duration and place, date and time of the activity as stated. This legal diligence
would include oral or written instructions, whether given before or during the activity, that if followed, would ensure the safety of
my child/ward ;
3. If my child/ward disregards or fails to follow these instructions or should act on his/her own, I, together with my child/ward, shall
be personally liable for any damage caused or liability be incurred to property or person;
4. For academic-related activities, in cases when my child/ward cannot join the off-campus activity due to valid reasons (e.g. illness,
financial constraints, emergency situations, etc.), I understand that other requirements of comparable academic weight may be
imposed on my child/ward in lieu of this activity;
5. For self-initiated activities, which are not organized, initiated, or sanctioned by the University, I hereby waive and release DLSU,
including its administrators, faculty, trainers, coaches, and other personnel, from all liability or claim that we may have in relation
to the attendance/participation of my child/ward in the said activities; and
6. If applicable, I allow my child/ward to go straight to the venue. We shall take full responsibility for the safety of my child/ward.

7. If applicable, I allow my child/ward to get off at __________________________________________ after the activity. We,
together with my child shall take full responsibility upon disembarking from the designated transportation.

STUDENT UNDERTAKING:
1. I confirm that I freely joined the academic or non-academic activity;

2. I acknowledge that this form is an official University document. Any misuse, unauthorized use, false representation, falsification,
tampering, or forgery will result to disciplinary action on the student pursuant to the Student Handbook (SH), which classifies
such act/s as a MAJOR OFFENSE;

3. I acknowledge that requests for approved absence, especially when the activity falls within class time, shall be subject to a
separate approval process and accomplishing this form is not an assurance that such absence shall be approved;

4. I acknowledge that I may be required to submit additional academic requirement or written learning outcome of comparable
academic weight in line with attending the activity;

5. For academic-related activities, in cases when I cannot join the off-campus activity due to valid reasons (e.g. illness, financial
constraints, emergency situations, etc.), I understand that other requirements of comparable academic weight may be imposed
on me in lieu of this activity;

Revised as of 27 May 2024

6. For self-initiated activities, which are not organized, initiated, or sanctioned by the University, I hereby waive and release DLSU,
including its administrators, faculty, trainers, coaches, and other personnel, from all liability or claim that we may have in relation
to my attendance/participation in the said activities; and

7. Likewise, if I participate in self-initiated (i.e., not DLSU sanctioned) activities, I understand that I will have to undergo a separate
process to secure clearance and permission to represent or use the name of the University.

__________________________________________________________

I hereby confirm that I am joining the said activity of my own free will.
I also understand that I will be subject to the applicable rules and regulations of the University.

________________________________________
Printed name and signature of Student
Mobile No. _______________________________
E-mail address: ___________________________

As proof that I am allowing my child/ward to attend this off-campus activity,

I affix my signature below and attach a photo of my government-issued ID.
I also understand that the University may confirm or verify the same
by contacting me through my contact details stated below.

________________________________________
Printed name and signature of Parent/Guardian
Mobile No. _______________________________
E-mail address: ___________________________

ACKNOWLEDGEMENT

BEFORE ME, a Notary Public for and in ________________, Philippines personally appeared the following
persons on ___________ who presented to me their competent proof of identities as follows:

Name Proof of Identity Issued at / Valid until

known to me to be the same persons who executed the foregoing form and acknowledge to me that the
same is their free and voluntary act and deed and that of the institutions they respectively represent.

This instrument refers to a Parent/Guardian Consent Form consisting of two (2) pages, including this page
whereon this Acknowledgement is written and signed by the parties and their instrumental witnesses.

WITNESS MY HAND AND NOTARIAL SEAL, at the date and place first mentioned.

Doc. No. ___;

Page No. ___;
Book No. ___;
Series of 20__.

Revised as of 27 May 2024