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Department of Education

Region X
Division of Bukidnon
Sumilao District
SAN VICENTE NATIONAL HIGH SCHOOL
San Vicente, Sumilao, Bukidnon

PARENT/GUARDIAN CONSENT REQUEST FORM
_______________
Date

Grade & Section: ______________

TO WHOM IT MAY CONCERN:
This is to certify that I allowed my son/daughter/ward to join the Band and Lyre Corps Competition.

Name of Son/Daughter
Name of Activity Band and Lyre Corps Competition
Date of Activity July 1,2017
Venue Poblacion, Sumilao, Bukidnon

Thank you very much!

Yours truly, Approved:

_____________________ _____________________
Name of Student Name of Parent
(Signature-Over-Printed Name) (Signature-Over-Printed Name)
---------------------------------------------------------------------------------------------------------------------------
STUDENT WAIVER
I, ___________________________________ (name) presently enrolled in ___________________
______________ (year & section) present myself to join the _________________________as part of
our school / student activity and do hereby pledge that:

1. I will obey and abide the rules and regulations promulgated, enforced by the officials/teachers of
San Vicente National High School for the protection and safety of all;

2. That I hereby waived and renounce my rights to all damages, hospitalization, and the like and I will
not hold the teachers staff of San Vicente NHS responsible for any misfortune, injury, or accident be
slight or serious, that may happen in connection with the activities or requirements. The cause of which
will be attributable to my acts of my disobedience, negligence, and the offense of my heading to advice,
warning, precaution, and safety rules that were read to me by my adviser before the start of the
activity.

That the content of this waiver was read and explained to me before I affix my name and signature
this ______ day of ______________freely and voluntarily.

Thank you very much!

Yours truly, APPROVED:

______________________________ ________________________________________
Name of Student Name of Parent/ Guardian
(Signature-Over-Printed Name) (Signature-Over-Printed Name)