URDANETA CITY College of Criminal Justice
UNIVERSITY Education
Parents/Guardian Conforme Form
Type of Activity: Carrying of Victim and Water Search and Rescue (Midterm)
College/Department: College of Criminal Justice Education Year Level: ________________________
Place: Barangay Sta. Maria, Binalonan, Pangasinan, Oria’s Resort
Inclusive Dates: ___________________________________________ Time: ______________________________
Person-in-Authority:_________________________________________ Contact Number: _____________________
For: Dean, The Student Affairs
I hereby willingly and voluntarily consent to the participation of my child
_______________________________________________________ to the aforementioned activity. I have
considered the benefits that my child will derive by participating in the activity. I understand that I will not hold any
party responsible for any untoward incidents which may happen in the course or duration or activity as long as proper
care and due diligence are observed to ensure the safety and security of my child.
____________________________________ __________________________ ___________________________
Signature over Printed Name of Parent/Guardian Relationship to the student (if Guardian) Date Signed
CONTACT INFORMATION:
Active Contact Number: _______________________ Email Address: _____________________________________
Home Address: ________________________________________________________________________________
Blk./Ph./ Lot/ House No. Street/ Subdivision Name Barangay
_____________________________________________________________________________________________
Municipality/ City Province/State/Country (if Abroad) Zip Code
STUDENT CONTRACT
I affirm that all information contained herein are true and correct, that I will not hold the institution responsible for any
untoward incidents that may happen due to personal negligence, irresponsible behavior, or lack of attention that will constitute a
violation of prearranged instructions given to insure my safety and security and therefore beyond the control of duly designated
adviser or faculty moderator. I also understand that all rules and policies pertinent to school activities are applicable and in
force.
Conforme:
______________________________________________ ________________________
Signature over Printed Name of Student Date Signed
For Strict compliance. Submit a notarized copy of this form to the Persons-in-Authority. Student without Parental Consent is not allowed to join the activity
mentioned above
(Please see the back for the complete guidelines)
SUBSCRIBED AND SWORN to before me this ____ day of ________________________, ________ in _______________________,
__________________, Philippines, personally appeared __________________________ and exhibited to me his
____________________________________________ issued at ____________________________.
NOTARY PUBLIC
Doc. No. _____
Page No. _____
Book No. _____
Series No. _____ SDSD Form 06
Parents/Guardian Confirmation Slip
Type of Activity: ________________________________________________________________________________
Place: _______________________________________________________________________________________
Inclusive Dates: ___________________________________________ Time: ______________________________
URDANETA CITY College of Criminal Justice
UNIVERSITY Education
Person-in-Authority:________________________________________ Contact Number: _____________________
SDSD Form 06
