Form A12.

1 (2017)
STUDENT ACTIVITIES AND LEADERSHIP DEVELOPMENT
Office of Student Affairs, Xavier University – Ateneo de Cagayan □ SACDEV Copy
Rm 204, 2/F Magis Student Complex (Tel) 853-9800 local 9245 □ Student’s Copy

STUDENT TRAVEL AGREEMENT/

PARENT’S CONSENT FORM
TO THE STUDENT ORGANIZATION:
Please input all necessary details of your off-campus activity (as indicated in your approved project proposal) in the table
below before disseminating this form to your participants. Pre-encoded information only serves as sample/guide.

TO THE STUDENT:
Please check accuracy of information provided by your student organization below. Present this form to your
parent/guardian and ask them to review the information provided before signing. Submit accomplished form to your
organization at least 3 days before your off-campus activity.

Name of Activity: Happy PICEta: A PICE XUSC Organization: PICE - XUSC

General Assembly and
Community Building 2018
Inclusive Date(s) of Activity: Venue: Don Arc Beach Resort
August 21, 2018

Accommodation: (for Stay-in) NA Address: Initao, Misamis Oriental 9022

Date of Departure: August 21, Time: 7:00 Mode/ Carrier: Hired Jeepney
2018 AM Plate Number:
Flight Number: If Applicable

Expected Date of Return to CDO: August 21, Time: 5:00 Mode/ Carrier: Hired Jeepney
2018 PM Plate Number:
Flight Number: If Applicable
TRAVEL AGREEMENT
In connection with my participation in the aforementioned activity and destination, I agree with and abide by the rules and
regulations set and imposed by the University for my own safety and for the welfare of everyone participating in the off-campus
activity.
1. No riding on the top load or boarding platform of the vehicle
2. Male and female students must be housed in separate rooms
3. Strictly no smoking and drinking of alcoholic beverages during the activity
4. No Gambling
5. Strict observance of the curfew imposed by my Moderator/Faculty supervisor (for stay-in/out-of-town activities)
6. All other provisions for security and safety of participants stated in the Implementing Guidelines for Off-Campus
Activities
Further, I hereby warrant and represent that:
1. I am voluntarily participating in the aforementioned activity;
2. I certify that I am in good physical health and physically able to participate in the described activity;
3. I acknowledge that I have discussed my travel and my participation with my parents/legal guardian who in turn gives
his/her full consent of my participation in the activity;
4. I shall strictly follow/abide by the duly approved schedule of our trip; In the event where unavoidable circumstances
occur and that changes are made in the schedule upon the discretion of my organization, I shall immediately notify my
parents/guardian of these changes;
5. I shall not deviate from the established and approved itinerary during the entire duration of the activity; In the event
where I am permitted by my parents to stay behind/ proceed to another destination after the activity, I declare that the
University is no longer responsible for me; Further, I acknowledge that I am solely responsible for my actions and
safety once I am already left on my own; (parents must write these remarks below)
6. In the event where I am allowed by my parents to use/drive my own vehicle or ride in a vehicle used by a co-
participant of the activity, I shall travel in convoy with the main vehicle loading all other participants; (parents must write
these remarks below)
7. I shall respect the duly designated school official (faculty/ staff member) who shall represent the University in the
enforcement of the guidelines stated herein and in the implementing guidelines for off-campus activities; and
8. Finally, I recognize the authority of the University to impose sanction on me for any misrepresentation and for failure to
abide by the rules and regulations for off-campus activities.
I have read, understood and acknowledge full acceptance and conformity with the foregoing conditions.

Student’s Name: _________________________________ Course and Year: ___________________

Student’s Address: ________________________________________________________________________

Student’s Mobile Number: ________________ Signature: _______________ Date: ______________

PARENT’S CONSENT
The undersigned parent/ guardian grants consent to my son/ daughter _________________________________ (name
of student) to participate in the aforementioned activity. Further, I have read, understood and denote full acceptance and
conformity with the foregoing conditions.
Parent/ Guardian’s Name: _________________________________ Relationship: ___________________

Contact Number: ____________________ Signature: _________________ Date: _______________

Parent’s Remarks (if any): __________________________________________________________________________

(Please submit the whole form to your organization.)