T I P - V P A A - 0 5 0 A

Revision Status/Date:3/2018 March 6

TECHNOLOGICAL INSTITUTE OF THE PHILIPPINES

P AR E NT ’ S CO NS E NT
PRIVACY CONSENT
I understand and agree that by filing out this form I am allowing the Technological Institute of the Philippines to collect, use, share, and disclose my personal
information for (specify purpose) and to store it as long as necessary for the fulfillment of the stated purpose and in accordance with applicable laws, including the
Data Privacy Act of 2012 and its implementing Rules and Regulations, and the T.I.P. Privacy Policy. The purpose and extent of collection, use, sharing, disclosure,
and storage of my personal information was explained to me.

This is to certify that I am allowing my son / daughter ___________________________________________________________

to join the institutional outreach program required under the course ______________________________________ for 2nd
Semester, SY 2018-2019 at ___________________________ on __________________.

As parent / guardian, I will do my part to remind my son / daughter to follow the rules and regulations of the field trips / off- campus
seminars.

If my son / daughter fail to observe the rules and regulations set under the course, TIP shall not assume any responsibility for any
injury or accident, personal or monetary, due to negligence or misconduct, which may happen to him / her within or outside the
venue throughout the duration of the field trips / off-campus seminars.

_________________________________________ ____________________________________
Printed Name and Signature of Parent / Guardian Date
(Please see attached photo copy of valid ID)

Address : ____________________________________________________________________________________________
Contact Number(s) : ____________________________________________________________________________________________

MEDICAL CLEARANCE
(to be accomplished by parent / guardian or physician)

Please check the appropriate box:

The above-named student has

 no pre-existing medical condition which will limit his participation in the activity.

 a pre-existing medical condition. Please check:

 Bronchial Asthma
 Epilepsy / Seizure
 Heart Condition
 Hypertension
 Diabetes Mellitus
 Disability
 Others (Please specify)________________________________
 He / She will bring his / her medication(s) to the activity
Noted by:

____________________________________________ ______________________________________
Printed Name / Signature of Parent, Guardian or Physician Printed Name and Signature of School Physician