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I, _____________________________________________, hereby name, appoint, and authorize,

(Name of Applicant/Student)

_____________________________________________(“Authorized Representative”), to act in my behalf

(Name of Authorized Representative)

and in my name to confirm my slot for admission at the Ateneo School of Medicine and Public Health

(“ASMPH”) for SY 2016-2017.

I hereby give and grant unto my Authorized Representative full powers and authority to do and

perform all and every act required or necessary to confirm my slot for admission at the ASMPH.

Furthermore, I hereby ratify and confirm all that my Authorized Representative shall lawfully do or cause

to be done by virtue hereof.

I do hereby quitclaim, release, discharge and waive any and all actions and/or liabilities of

whatever nature, expected, real or apparent, which I may have against ASMPH, its officers, employees and

agents by reason of or arising from my failure or inability to fulfill any of the pending requirements for

admission accordingly indicated in the letter of acceptance duly received and explained to my Authorized

Representative upon confirmation of my slot for admission.

I declare that I have read and understood this document, and have sought counsel, if necessary, to

fully understand its contents. I further declare that I voluntarily and willingly executed this Authorization,

Release, Waiver and Quitclaim with full knowledge of my rights and liabilities under the law.

IN WITNESS WHEREOF, I have hereunto set my hand this ___ day of _________ 2016, in


_____________________________________ _____________________________________
Signature over Printed Name of the Accepted Applicant Signature over Printed Name of the Authorized Representative
Date Signed: ________________________________ Date Signed: ________________________________

Signed in the Presence of:

_____________________________ _____________________________

1Required Attachments:
Original and photocopy of the accepted applicant’s ID
Original and photocopy of the authorized representative’s ID


_____________________________________ ) S.S.

BEFORE ME , a Notary Public for and in the __________, this ___________________, personally
appeared the following:

Name ID/Passport/CTC Place of Issue Date of Issue

known to me and to me known to be the same person/s who executed the foregoing
Authorization, Release, Waiver and Quitclaim consisting of 2 pages including the page on which
this Acknowledgment is written, and who acknowledged to me that the same is their free and
voluntary act and deed.

IN WITNESS WHEREOF, I have placed my hand and seal on the date and at the place first

Doc. No.:
Page No.:
Book No.:
Series of 2016.