St. Mary’s College Basic Education Department St.

Mary’s College Basic Education Department

Quezon City SY 20__-20__ Quezon City SY 20__-20__

Device Permit Form Device Permit Form

Name: ________________________________________ Name: ________________________________________

Grade and Section: ______________________________ Grade and Section: ______________________________
Date Requested: _______________________________ Date Requested: _______________________________

Device to be brought in school Device to be brought in school

o laptop
o camera
o others _________________
Purpose:
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Inclusive Date/s and Place to be used:
_____________________________________________
o laptop
o camera
o others _________________
Purpose:
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Inclusive Date/s and Place to be used:
_____________________________________________

Endorsed by: Endorsed by:

_____________________________________________ _____________________________________________
Class Adviser/Subject Teacher/Club Moderator’s Signature Above Printed Name Class Adviser/Subject Teacher/Club Moderator’s Signature Above Printed Name

_____________________________________________ _____________________________________________
Subject Area Coordinator/Academic Coordinator/PAC/STAC Subject Area Coordinator/Academic Coordinator/PAC/STAC

Note: The security and protection of the device will be the Note: The security and protection of the device will be the
sole responsibility of the pupil/student. The school will sole responsibility of the pupil/student. The school will
not be in any way held liable for any lost or damage of not be in any way held liable for any lost or damage of
the device. the device.

Requested by: Requested by:

_________________________________ _________________________________
Parent’s Signature Above Printed Name Parent’s Signature Above Printed Name

Approved by: Approved by:

_____________________________________________ _____________________________________________
Discipline Coordinator Discipline Coordinator