Republic of the Philippines
North Eastern Mindanao State University
Formerly Surigao Del Sur State University
Cantilan Campus
Cantilan, Surigao del Sur
Telefax No. 086-212-5132
Website: [Link]
Name: _____________________________ Age: _______ Course/Yr./Section: ____________
Address: _____________________________Contact No: _____________________________
Pease check appropriate box
Sports Field Trip
Cultural Extension /Research
Research Students Congress
Training Others Please specify_______________
PARENTAL CONSENT
This is to certify that I have full knowledge of and permission for my son/daughter to
__ATTEND __NOT TO ATTEND the ___________________________ on
______________________.
I concur and agree on the rules, policies and regulations being implemented by the
school and the concerned instructors/professors. I have duly advised my son/daughter to
exercise all precautions and necessary safety measures. That I am aware that the University
has conducted pre-departure briefing to secure my child in this endeavor.
_______________________________ _____________________________
Signature over Printed Name Signature Over Printed Name of
Parent/Guardian Adviser
________________________________ ______________________
Dean of the College Campus Director/VPAA
In witness thereof I have hereunto set a Notarial Seal on this ______ day of 20____ at
_____________, Surigao del sur, Philippines.
Doc: _____________
Page No: __________
Book No: __________
Series No: _________
NOTARY PUBLIC
