Republic of the Philippines

DON HONORIO VENTURA STATE UNIVERSITY

Bacolor, Pampanga

RELEASE OF LIABILITY, PROMISE NOT TO SUE,

ASSUMPTION OF RISK AND AGREEMENT TO PAY CLAIMS

Activity:__________________________________________________________________________________________
__________________________________________________________________________________________________
____________________________________________________

Activity Date (s) and Time (s): _________________________________________________________

Activity Location (s): _________________________________________________________________

In consideration for being allowed to participate in this Activity, on behalf of myself and my next of kin, heirs
and representatives, I release from all liability and promise not to sue the Don Honorio Ventura State
University, the Board of Regents of Don Honorio Ventura State University, their employees, officers, directors,
volunteers and agents (collectively “University”) from any and all claims, including claims of the University’s
negligence, resulting in any physical or psychological injury (including paralysis and death), illness, damages, or
economic or emotional loss I may suffer because of my participation in this Activity, including travel to, from
and during the Activity.

I am voluntarily participating in this Activity. I am aware of the risks associated with traveling to/from and
participating in this Activity, which include but are not limited to physical or psychological injury, pain, suffering,
illness, disfigurement, temporary or permanent disability (including paralysis), economic or emotional loss,
and/or death. I understand that these injuries or outcomes may arise from my own or other’s actions, inaction, or
negligence; conditions related to travel; or the condition of the Activity location(s). Nonetheless, I assume all
related risks, both known or unknown to me, of my participation in this Activity, including travel to, from
and during the Activity.

I agree to hold the University harmless from any and all claims, including attorney’s fees or damage to my
personal property, that may occur as a result of my participation in this Activity, including travel to, from and
during the Activity. If the University incurs any of these types of expenses, I agree to reimburse the University.
If I need medical treatment, I agree to be financially responsible for any costs incurred as a result of such
treatment. I am aware and understand that I should carry my own health insurance.

I am 18 years or older. I understand the legal consequences of signing this document, including (a) releasing
the University from all liability, (b) promising not to sue the University, (c) and assuming all risks of
participating in this Activity, including travel to, from and during the Activity.

Participant Signature: _______________________________________

Participant Name (print): ____________________________________ Date: ____________

Noted:

Parent’s Signature:_________________________________________

Parent’s Name (print):_______________________________________ Date: ____________

If Participant is under 18 years of age:

I am the parent or legal guardian of the Participant. I understand the legal consequences of signing this
document, including (a) releasing the University from all liability on my and the Participant’s behalf, (b)
promising not to sue on my and the Participant’s behalf, (c) and assuming all risks of the Participant’s
participation in this Activity, including travel to, from and during the Activity. I allow Participant to
participate in this Activity. I understand that I am responsible for the obligations and acts of Participant as
described in this document. I agree to be bound by the terms of this document.

I have read this two-page document, and I am signing it freely. No other representations concerning the legal
effect of this document have been made to me.

________________________________________________________
Signature of Minor Participant’s Parent/Guardian

________________________________________________________ ________________
Name of Minor Participant’s Parent/Guardian (print) Date

________________________________________________________
Minor Participant’s Name
 Don Honorio Ventura State University
Bacolor, Pampanga
OFF-CAMPUS ACTIVITY FORM

CURRICULAR ACTIVITY

OSA Form 001 Date Filed_______________________

Name of Organization______________________________________________________________
Activity_________________________________________________________________________
Date(s) of Activity_____________________ Time: Start________ End________
Venue and Address of the Activity____________________________________________________
No. of Participants________________________________________________________________
Officer(s)-in-Charge____________________________ Position_________________________
President Vice President Others, please specify _________________________
_______________________________________________________________________________
Advisers Undertaking

We hereby declare that we have knowledge of and consented to the holding of the abovementioned activity. We
hereby undertake to be present throughout the said activity to oversee the behaviour of the participants and ensure with
utmost diligence, their safety and physical well-being.
This, however, shall not in any way be construed as an admission of personal liability which may result from the said
activity, unless the same is clearly shown to have been caused by our own negligence or omission.

________________________________ ________________________________
Signature over Printed Name of Adviser Signature over Printed Name of Adviser

Noted by:

______________________________________
College Dean (for College- Based Student Groups)

________________________________________________________________________________
Checklist of Requirements (to be submitted 2 weeks prior to the activity)

For overnight activity: Duly notarized parental consent for each participant
For whole day activity: Acknowledgement letter from parent/guardian with photocopy of parents/guardian’s valid ID.
Itinerary for the activity
Medical Certificate/Clearance (for physical and/or strenuous activities) issued by the University Physician
Meeting with parents of attendees (optional)
Breakdown of expenses (for organizational tour)
Attendance Sheet

______________________________________________________________________________
Reminders:
 Submit the Narrative Report with proper documentation, showing the presence of the advisers
 Duly accomplished Off-Campus Activity Attendance Sheet attached to the narrative report
 Off-Campus Activity Form must be submitted at least 2 weeks before the activity.
 To be submitted in three (3) copies, to the Office of Student Affairs
Requested by: _____________________________
Position:__________________________________

Approved: _______________________________
Director, Student Affairs
 Don Honorio Ventura State University
Bacolor, Pampanga
OFF-CAMPUS ACTIVITY FORM

NON-CURRICULAR ACTIVITY

OSA Form 002 Date Filed_______________________

Name of Organization______________________________________________________________
Activity_________________________________________________________________________
Date(s) of Activity_____________________ Time: Start________ End________
Venue and Address of the Activity____________________________________________________
No. of Participants________________________________________________________________
Officer(s)-in-Charge____________________________ Position_________________________
President Vice President Others, please specify _________________________
_______________________________________________________________________________
Advisers Undertaking

We hereby declare that we have knowledge of and consented to the holding of the abovementioned activity. We
hereby undertake to be present throughout the said activity to oversee the behaviour of the participants and ensure with
utmost diligence, their safety and physical well-being.
This, however, shall not in any way be construed as an admission of personal liability which may result from the said
activity, unless the same is clearly shown to have been caused by our own negligence or omission.

________________________________ ________________________________
Signature over Printed Name of Adviser Signature over Printed Name of Adviser

Noted by:

______________________________________
College Dean (for College- Based Student Groups)

________________________________________________________________________________
Checklist of Requirements (to be submitted 2 weeks prior to the activity)

For overnight activity: Duly notarized parental consent for each participant
For whole day activity: Acknowledgement letter from parent/guardian with photocopy of parents/guardian’s valid ID.
Itinerary for the activity
Medical Certificate/Clearance (for physical and/or strenuous activities) issued by the University Physician
Meeting with parents of attendees (optional)
Breakdown of expenses (for organizational tour)
Attendance Sheet (OSA Form 004)

______________________________________________________________________________
Reminders:
 Submit the Narrative Report with proper documentation, showing the presence of the advisers
 Duly accomplished Off-Campus Activity Attendance Sheet attached to the narrative report
 Off-Campus Activity Form must be submitted at least 2 weeks before the activity.
a) Form 001 b) Form 002 c) Form 003 d) Form 004
 To be submitted in three (3) copies, to the Office of Student Affairs
Requested by: _____________________________
Position:__________________________________

Approved: GLORIA B. GIGANTE, Ed.D

Director, Student Affairs
 Don Honorio Ventura Technological State University
Bacolor, Pampanga

OFF-CAMPUS ACTIVITY

ATTENDANCE SHEET

OSA Form 003

I hereby certify that the above listed students personally appeared before me on the date as specified

________________________________

Person-In-Charge (PIC)
 Don Honorio Ventura Technological State University
Bacolor, Pampanga

ROLE OF PERSON-IN-CHARGE (PIC)

OSA Form 004

Duties and Responsibilities of PIC

1. Accompany the students from the time they assemble for the off-campus activity up to debriefing.

2. Ensure the provision of the allowable seating capacity of the vehicle(s) used. (No student should be allowed to

ride on the roof of motor vehicle or on the boarding platform).

3. Ensure that program of activities is properly followed as planned or activities can be adjusted as the need arises.

4. Have first aid kit available anytime.

5. Coordinate to the proper authorities in case of untoward incident such as accidents, injury, etc.

6. Make the necessary recommendation (s), in case of bad weather, either to cancel/postpone the said activity.

Reference:

CHED Memorandum Order #63 series of 2017