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WAIVER/UNDERTAKING

We, (student-trainee)
(parent/ guardian), hereby execute this Waiver/ Undertaking to hold the Polytechnic
University of the Philippines and the training institution free from any liability for
any injury / illness / loss of life or property that may be incurred/ sustained by the
student-trainee in the course of his/ her on-the-job-training / practicum with the
training institution provided that the same is not due to any willfull criminal act or
gross negligence of the training institution or any of its representatives, officers or
employees.

As the parent/ guardian of the student-trainee, I hold myself responsible for any
expenses that may be incurred as a result of the students illness, injury, death or
loss or property in the course of the students on-the-job training/ practicum, except
as provided above. I further undertake to be responsible for any breakage, loss of
property, damage, death or injury that may be caused by the student-trainee to any
party while undergoing training.

We execute this Waiver/ Undertaking in accordance with our free will, realizing the
benefits that the student-trainee shall obtain from the said on-the-job training /
practicum.

(Printed Name and Signature of (Printed Name and Signature


of
Student-Trainee) Parent/ Guardian)

REPUBLIC OF THE PHILIPPINES )


CITY OF )

Subscribed and sworn to before me affiants exhibiting valid proofs of their


identity as
follows:

Name ID No. Issued at/on

_________________________ __________________ ____________________________________

_________________________ __________________ ____________________________________

They acknowledged to me that the foregoing Waiver/ Undertaking was


executed in accordance with their own free will.

NOTARY PUBLIC

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