2 X 2 ID picture

Republic of the Philippines

CAGAYAN STATE UNIVERSITY
College of Human Kinetics
Carig Campus, Tuguegarao City

MENTEE’S PERSONAL INFORMATION

NAME OF MENTEE: AGE:

DATE OF BIRTH: WEIGHT: HEIGHT:

ADDRESS: CONTACT #:

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MEDICAL CERTIFICATE

This is to certify that____________________________________ is Physically Fit to participate and be

deployed for their Field Study at _________________________________ from October 10 to December 07,
2018.
_________________________________
Printed Name and Signature of Physician

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MENTEE’S WAIVER AND RELEASE AGREEMENT
In consideration of the acceptance of my entry, myself, my heirs, executors, administrators and assigns, do
hereby release and discharge the Field Study Instructors, faculty members of the College of Human Kinetics,
and the Cagayan State University from claims and damages, demands or actions whatsoever in any manner
arising from or growing out of my participation in, or while traveling to and from my deployment to my
respective cooperating school. I further attest and verify that I have obtained the necessary clearance from
my medical doctor and guaranteed Physically Fit to participate in the Field Study from October 10 to
December 07, 2018.

PARENT/GUARDIAN PERMIT
This is to certify that I have full knowledge and permission for my son/daughter/foster child to join and
participate in the Field Study. I concur and agree on the rules, policies and regulations being implemented
by the concerned faculty members.

________________________ __________________________
Mentee’s Signature Parent/Guardian Signature