NIPSCFoSRSASNo.

03
Revised June 2004

Republic of the Philippines

NORTHERN ILOILO POLYTECHNIC STATE COLLEGE
Estancia, Iloilo

OFFICE of the STUDENT and AUXILIARY SERVICES

STUDENT’S PLEDGE AND WAIVER

I, , whose signature appears below, student of Northern

Iloilo Polytechnic State College, Estancia, Iloilo hereby state:

1. That I promise to obey and abide all the rules and regulations promulgated and
enforced by the Northern Iloilo Polytechnic State College, its officials and duly
constituted authorities;

2. That the Northern Iloilo Polytechnic State College, its officials, teachers and
employees, agents and representatives, shall not be held liable for any accident, harm,
and/or injury that may happen to me while in the performance of my duties and
assignments as a student the cause of which is due to my failure to heed all warnings,
cautions, signs, and/or advice and/or my neglect to obey and abide by the rules and
regulations prescribed and promulgated by the school officials and all other duly
constituted authorities, and I hereby further waive and renounce my rights to claim for
damage against the Northern Iloilo Polytechnic State College, its officials, teachers and
employees, agents and/or representatives for any accident, harm or injury that may
happen to me in the manner and time above specified;

3. That I have read and fully understood the contents of this pledge and waiver and
I affix my signature hereto freely and voluntarily without mental reservation or purpose
of evasion.

Date Signature of the Student

PARENT’S OR GUARDIAN’S AGREEMENT/CONSENT

I, whose signature appears below,

parent/guardian of hereby give permission to join
the socio-educational trip/tour to

translated to me the contents of the foregoing pledge and waiver signed by

consent with and concur in the same without any mental reservation or purpose of
evasion.

Date Signature of the Parent

Address