SLU NSTP

NATIONAL SERVICE TRAINING PROGRAM (NSTP) OFFICE Form 20

(NOV.
COMMUNITY EXTENSION and OUTREACH PROGRAM OFFICE (CEOPO) 2017)
SAINT LOUIS UNIVERSITY
Student Center First Basement, Assumption Rd., 2600 Baguio City
Tel: 09205291972; (074) 444-8246 to 48; FAX: (074) 442-2842
E-address: charmainemendoza.0512@gmail.com
CICM SLU NSTP CICM SLU NSTP CICM SLU NSTP CICM SLU NSTP CICM SLU NSTP CICM SLU NSTP CICM SLU NSTP CICM SLU NSTP CICM

PARENTS/AUTHORIZED GUARDIANS CONSENT

NSTP CWTS Class Code:7056 Lesson Title/Apostolate Name: ___________________________________
Term:1st School Year:2017-2018 Instructor: Joppie S. Coyupan
Date Time Place Activity Highlight

Prince Bernhand Gym,

November 5, 2017 1:00 PM 5:00 PM
Saint Louis University

NOTE: PLEASE WRITE ADDITIONAL ENTRIES AT THE BACK PAGE OF THIS WAIVER
WHEREAS, the NSTP CWTS (Civic Welfare Training Service) class will hold the community exposure/community service practicum which is part of the
requirements of the training course herein specified:
WHEREAS, the activity is aimed at enhancing civic consciousness and the ethics of service among the youth by inculcating in them sense of patriotism and
nationalism through their involvement in civic affairs translated into modified community immersion and integration;
WHEREAS, the University allows this activity in consonance with the training provisions of the NSTP Law, with the written consent of their parent/guardians, as
well as with the supervision by their instructor who faithfully and honestly observe the diligence and care within the bounds of the law to prevent any untoward incident/s,
to uphold the rules and regulations of the University governing such activity and the violation thereof will make the person/s concerned liable thereof;
WHEREAS, the rules and regulations governing the activity are as follows:
For the INSTRUCTOR:
1. Diligently guides the students in accordance with prudence and as per rules and regulations of the University governing off-campus activities and
the conduct of students outside the school;
2. Orients students on activity guidelines or instructions before the activity proper;
3. Responsible only for the consequence due to negligence on this part;
4. Not liable for any untoward incident due to:
a. Violation of activity rules and regulations or instructions;
b. Negligence on the part of the student;
c. Unforeseen events by nature;
d. Accidents beyond control;
e. His absence, that is not within the period covered;
f. Force major, including civil disturbance or riots; and
g. Assumption of risk by the student/s.
For the STUDENT:
1. Student activities are governed by school rules and regulations;
2. Student are required to observe and follow the policies, rules and regulations of the University as stated in the Student Handbook regarding a
bonafide Louisian and his/her conduct and behaviour.
3. Students are required to observe and follow the regulations and instructions imposed by the Instructor before and/or during the activity as
warranted;
4. Students are responsible for any act or untoward incident if the cause is:
a. due to negligence on his/her part;
b. violation of rules and regulations or instructions;
c. not covered by the period defined under the instructors duties and responsibilities.
5. The student participates only WITH parental/guardians CONSENT properly accomplished.
I _________ , have read and understood the above provisions regarding the required
community activity, I will faithfully observe and follow the above provisions to achieve the objectives of the activity and to avoid
occurrence of any untoward incident.

Attested by:
JOPPIE S. COYUPAN
Instructors Name and Signature Students Name and Signature
Date: November 4, 2017 Contact No: Group No:____ Date: November ,2017

Endorsed by: Noted by:

CHARMAINE P. MENDOZA ALBERT G. GUINGUINO JR.
NSTP Coordinator (09205291972) OIC - CEOPO
Date: Date: ________

PARENTS/GUARDIAN/S CONSENT
(note: ONLY PARENTS, OR GUARDIANS AUTHORIZED BY PARENTS ARE RECOGNIZED TO SIGH BELOW, IF SIGNATORY IS NOT THE PARENT, CONCERNED STUDENT
SHOULD CONSULT FIRST THE NSTP COORD OR SI BEFORE SECURING SIGNATURE FROM A GUARDIAN OTHER THAN THE PARENT)
I allow ( ) do not allow ( ) my child/ward to join the community activity as stated above and will not hold the University and/or its
representatives liable for any toward incident that may arise

Contact No: Date:

Parents Guardians Name and Signature
To the Student: submit/return to the NSTP Office this duly accomplished parents consent before participating in the activity or as instructed by your instructor.
Guardians who do not allow their ward to join the activity are required to explain in writing why concerned ward is not allowed. This is in order to determine
appropriate alternative activity for such student. Always attach to this waive a photocopy of the ID with signature specimen of the parent or authorized guardian
signing this waiver. FAILURE TO ACCOMPLISH THIS WAIVER PROPERLY WILL CAUSE DEMERIT ON THE STUDENT CONCERNED.

NSTP OFFICE REMARKS ON THE PROPER ACCOMPLISHMENT AND PROCESSING OF THE WAIVER:
MERITS: DEMERITS:
CICM SLU NSTP CICM SLU NSTP CICM SLU NSTP CICM SLU NSTP CICM SLU NSTP CICM SLU NSTP CICM SLU NSTP CICM SLU NSTP CICM

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