Republic of the Philippines

JOSE RIZAL MEMORIAL STATE UNIVERSITY

The Premier University in Zamboanga del Norte
Siocon Campus
Siocon, Zamboanga del Norte

AFFIDAVIT OF WAIVER

I, ___________________________________ of legal age, single/married and a resident

of ____________________________ Zamboanga del Norte, Philippines, after having been sworn
to in accordance with law, depose and say;

That I am the legal or legitimate parent/guardian of __________________________who

is presently enrolled at the JOSE RIZAL MEMORIAL STATE UNIVERSITY, Siocon Campus,
Siocon, Zamboanga del Norte.

That as part of the curricular activities, I hereby approve the participation of my

daughter/son, _____________________ to undergo hospital duty to be conducted at Zamboanga
del Norte MEDICAL CENTER, Dipolog City from __________________________________,
201 .

That, I have to pay an amount for our chaperon, and other fees which may occur during
orientation and until their scheduled training ends.

That, I have considered the benefits that my daughter/son will acquire by his/her
participation.

In the above mentioned activity with the understanding that every precaution shall be taken
by Jose Rizal Memorial State University (JRMSU) official concerned to ensure his/her safety
during the said activity.

That, I hereby agree that the JRMSU officials or its representative shall not be held liable
for any untoward incident that may happen beyond their control.

THEREOF, I waive all my rights to file charges against the JRMSU officials of tis
representative.

IN WITNESS WHEREOF, I hereby set my hands this ____________ day of

____________, 2016, at Siocon Zamboanga del Norte.

__________________________
(Affiant)
Parent/Guardian

SUBSCRIBED AND SWORN to me before this _________ day of ________, 2016,

affiant exhibited his Residence Certificate No. _______________ issued at
__________________________ on ___________________, 2016.

___________________________________
Signature of Person Administering Oath