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ERESERVE No. 42665 For Extra -Curricular Activities (students copy page 1 of 2) UNIVERSITY OF

ERESERVE No. 42665

For Extra-Curricular Activities (students copy page 1 of 2)

UNIVERSITY OF SANTO TOMAS

España, Manila

Junior Pharmacists' Association - Gamma Chapter - FACULTY OF PHARMACY

Dear Parents/Guardians:

NAME OF ORGANIZATION

Your son/daughter/ward has expressed his/her intentions of joining the

Seniors Retreat

sponsored by the

(TITLE OF ACTIVITY/EVENT)

Junior Pharmacists' Association - Gamma Chapter - FACULTY OF PHARMACY

to be held on

(NAME OF SPONSORING CLASS/ORGANIZATION)

Sept. 30-Oct. 2,2016, Oct.7-9, 2016, Oct14-16,2016 at Off-Campus (Caleruega Retreat House, Batulao, Nasugbu, Batangas) .

(DATE AND TIME OF ACTIVITY)

(LOCATION: COMPLETE ADDRESS OF VENUE)

Should you allow your son/daughter/ward to join the aforementioned activity, kindly fill-out the attached "Statement of Parental Consent" and

return the same to

Mycaela De Alva

the

Secretary

(NAME OF OFFICER)

(POSITION IN THE ORGANIZATION)

of the

Junior Pharmacists' Association - Gamma Chapter - FACULTY OF PHARMACY

on or before

(NAME OF ORGANIZATION)

August 25,2016

.

(DEADLINE FOR SUBMISSION OF STUDENT UNDERTAKING AND STATEMENT OF PARENTAL CONSENT)

Sincerely yours,

(SIGNATURE OVER PRINTED NAME OF FACULTY ADVISER)

Noted:

(SIGNATURE OVER PRINTED NAME OF DEAN)

ADVISER) Noted: (SIGNATURE OVER PRINTED NAME OF DEAN) STUDENT UNDERTAKING AND STATEMENT OF PARENTAL CONSENT This

STUDENT UNDERTAKING AND STATEMENT OF PARENTAL CONSENT

This copy to be retained by the faculty (waiver form 2011 series for enjoined activity)

For Extra-Curricular Activities (organizer's copy page 1 of 2)

Activity Title:

Seniors Retreat

 

Where:

Off-Campus (Caleruega Retreat House, Batulao, Nasugbu, Batangas)

When:

Sept. 30-Oct. 2,2016, Oct.7-9, 2016, Oct14-16,2016

Nature of Activity:

Religious Activity/Retreat/Recollection

 

College/Organization (Organizer):

Junior Pharmacists' Association - Gamma Chapter - FACULTY OF PHARMACY

Person/Officer-in-Charge: Mycaela De Alva Position: Secretary

 

Mobile No.: 09956314660

Tel. No.: (02)-522-4694

 

E-Mail: mycaela_dealva@yahoo.com

STUDENT UNDERTAKING, WAIVER AND STATEMENT OF PARENTAL CONSENT

FIRST NAME MIDDLE NAME LAST NAME STUDENT NO. ADDRESS MOBILE NO. LANDLINE NO. E-MAIL Name
FIRST NAME
MIDDLE NAME
LAST NAME
STUDENT NO.
ADDRESS
MOBILE NO.
LANDLINE NO.
E-MAIL
Name of person to be contacted in case of emergency:
Contact Nos.:

I, whose name appears above, hereby express my intention to join the above stated activity, organized Junior Pharmacists' Association - Gamma Chapter - FACULTY OF PHARMACY

Sept. 30-Oct. 2,2016, Oct.7-9, 2016, Oct14-16,2016

by the

to be held on

.

In connection with the above mentioned activity, I hereby warrant and represent that:

1. I understand that my participation in the said activity is voluntary AS THE SAME WILL NOT AFFECT MY ACADEMIC STANDING SHOULD I DECIDE NOT TO JOIN, and that said activity is only for the primary purpose of achieving my holistic growth as an individual and enhancing my personal development, especially as a student of the University of Santo Tomas.

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ERESERVE No. 42665

For Extra-Curricular Activities (students copy page 2 of 2) I. PARTICIPATION GUIDELINES I. GUIDELINES ON
For Extra-Curricular Activities
(students copy page 2 of 2)
I. PARTICIPATION GUIDELINES
I. GUIDELINES ON REGISTRATION and
PAYMENT
II. MAP
1.
Participants are expected to have read and
conformed to the student undertaking guidelines
set by the off-campus activity organizers.
2.
Only students who have submitted their
Student’s Undertaking will be allowed to
participate.
3.
Bring the ff:
-
Personal Medicine/s (if you have allergies etc.)
Snacks/Food
– Flashlight
-
-
Extra Clothes
-
Toiletries
Something handy that is important or valuable
to you
-
- Drinking water and personal water bottle
- Sunblock and Off lotion
- Ballpen/Pen
III. FLOOR PLAN
IV. OTHER DETAILS
lotion - Ballpen/Pen III. FLOOR PLAN IV. OTHER DETAILS For Extra -Curricular Activities (organizer's copy page

For Extra-Curricular Activities (organizer's copy page 2 of 2)

2. Having volunteered attendance and participation in such an activity I take it as my responsibility to take the necessary precaution or care of avoiding or getting involved in any incident that would cause slight, serious or mortal injury upon my person or results in the loss or damage to my property and that of other person.

3. I also understand that I am not to engage in any behavior that could or may lead to any incident or could result to loss or damage to property, injury to myself or other person(s).

4. I understand that it is my responsibility to fully ascertain, if necessary with the help of a medical professional, my physical and mental fitness to join this activity.

5. I understand that I must be sufficiently healthy or free from any medical condition that maybe exacerbated or aggravated by my participation in such an activity. Should I be suffering from any medical condition that maybe aggravated or exacerbated by such an activity, I commit to immediately report such condition in writing to the assigned faculty adviser and

excuse myself from such an activity. I have not been sick, injured, nor confined to a hospital or suffered any medical condition

and as evidence by the attached Medical

since my last medical examination conducted on (mm) Examination Report.

(dd)

(yy)

6. I have properly informed my parents or the person(s) exercising parental authority over my person concerning the nature of the activity which I am joining and likewise secured their advice on the measures which I am to undertake for my personal safety and security. Furthermore, I have secured their consent for me to join such an activity as evidenced by the signature appearing herein.

7. I am fully convinced that the University and the faculty adviser(s) and organizer(s) of this particular activity have exercised sufficient diligence and care in the preparation and implementation of this activity.

8. Considering the voluntary nature of the said activity. I hereby hold the University of Santo Tomas and its representative(s), adviser(s) free and harmless from any liability which may arise out of this activity.

Attention: For the student, parent or person exercising parental authority over the student concerned, affixing your signature herein shall mean that you conform, agree to the conditions stated above and consent to the participation of your son/daughter/ward in the said activity and, further hold the university free and harmless from any liability arising from the said activity.

SIGNATURE OF STUDENT

SIGNATURE OF PARENT/GUARDIAN

STUDENT'S NAME IN PRINT

PARENT/GUARDIAN'S NAME IN PRINT

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