Republic of the Philippines

EASTERN VISAYAS STATE UNIVERSITY

Tacloban City

Student Affairs and Services Office

STUDENT AFFAIRS OFFICE

PARENT’S PERMIT

We/I hereby grant permission to our daughter/son JONATHAN P. SOYOSA to participate in the
CE 503 ( FIELD TRIPS AND SEMINARS) to be held at __________________ on ____________________

We/I fully understand that all the necessary precautions will be taken into consideration to ensure safety and well-being of
my / our child for the duration of the said activity. However, we/I cannot hold the chaperon or instruction or companion of the
school responsibility for any incident or unforeseen circumstances that may happen beyond control.

CARLITO P. SOYOSA
Parents / Authorized Guardian

I hereby certify that the signature that appears above is therefore genuine

JONATHAN P. SOYOSA
Signature over Printed Name of the Student

WENCESLAO C. PERANTE, Ph. D.

Signature over Printed name of the Adviser

Recommending Approval:

DIOSCORO Y. MANCAO Jr., Ph. D. ANNABELLE B. PILAPIL, Ph. D.

Signature over Printed Name of the Dept, Head Signature over Printed Name of the College Dean

Approved:

SONIA T. ENRILE, MAED

Head, Student Affairs Office

Medical Section
MEDICAL CERTIFICATE
Date:_________________

This is to certify that, _________________________________________________ years old from EASTERN VISAYAS STATE
UNIVERSITY- _________________________ came in to this clinic on _____________________________ for

( ) Physical Examination ( ) Treatment as out-patient

IMPRESSION/ DIAGNOSIS:

REMARKS/DISPOSITION: ( ) Physically and mentally fit / unit

( ) Advised continuous treatment at home and regular check-up
( ) Advised rest for ________________ days/ weeks/ months

MA. SALUD N. ROSILLO, M.D

Medical Officer lll
License No. 82635
PTR No.
ACKNOWLEDGEMENT
Republic of the Philippines)
City of Tacloban ) SS.

SUBSCRIBED AND SWORN to before this ________________________________ day of ________, 2018

________________________________________ , Philippines.