Republic of the Philippines

Leyte Normal University

College of Education
PROFESSIONAL EDUCATION UNIT
Tacloban City

Parents’ or Guardians’ Consent Form

TO WHOM THIS MAY CONCERN:

This certifies that ___________________________________, a _____________

of the College of ___________________ with Student No. ________________ has the
permission of his/her undersigned parent(s) or guardian(s) to conduct a Field Study Activity in
_____________________________________________________________________ (school),
________________________ (school’s address) on ___________________, 20_____.

The activity that the above student will be undertaking is part of his/her requirements for
the subject Field Study _____. This is in consonance with the implementation of Experiential
Learning Courses (ELCs) under the New Teacher Education Curriculum, per CMO No. 30, s. 2004,
where the field study students (FSS) are required to conduct field study activities in a particular
school where they can observe, verify, and reflect on actual learning experiences to bridge theory
and practice. A Memorandum of Agreement (MOA) has been signed to this effect by Dr. Jude A.
Duarte for Leyte Normal University and Dr. Thelma C. Quitalig for the Department of Education.

This certifies further that risk assessment plans and necessary safety and precautionary
measures have been instituted. Any untoward incidents that may happen during the conduct of
the activity, the institution will not be held liable.

Furthermore, the following faculty member/s shall also be present in the assigned school
mentioned above to monitor the field study activity.

Faculty Name (Please Print) Faculty Signature

________________________________________ _____________________
________________________________________ _____________________
________________________________________ _____________________

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I/We have honestly and accurately completed all parts of the Parents’ or Guardians’
Consent Form to the best of my/our ability.

__________________________________ ________________________________
Parent’s/Guardian’s Signature Parent’s/Guardian’s Signature

__________________________________ ________________________________
Parent’s/Guardian’s Name (Please print) Parent’s/Guardian’s Name (Please print)

Complete Address: Complete Address:

__________________________________ ________________________________
__________________________________ ________________________________

ID Type and Number: ID Type and Number:

__________________________________ ________________________________

Contact Number/s: Contact Number/s:

__________________________________ ________________________________