Internship Waiver Form

I am ______________________________________, ______ yrs. old and a _____ year student

of Eastern Visayas State University- Ormoc City Campus.
In partial fulfilment of the requirements for my degree of Bachelor of Science in Civil
Engineering, I shall be undergoing an internship training for a total of _______ hours starting on
_______________ until _________________, at _____________________________________.

In relation to the said internship training:

a.) I take it as my responsibility to take the necessary precautions to avoid or get involved in
any incident that could cause los, damage or injury to my own person or that of another:

b.) I understand that it is my responsibility to fully ascertain, if necessary, with the help of a
medical professional, my physical and mental fitness to join such activity.

c.) I understand that I must be sufficiently healthy or free from any medical condition that
may be exacerbated or aggravated by my participation in such activity. Should I be
suffering from any medical condition that may be exacerbated or aggravated by
participating in such activity, I commit to immediately report the same in writing to the
assigned faculty coordinator and excuse myself from the said activity.

d.) I hereby declare that I understand that I should strictly observe

________________________________’s (insert name of institution or company where
the internship training is to be conducted) rules on security and confidentiality of
business information and other regulations that may be implemented by my direct
supervisors and our faculty coordinator in relation to my training:

e.) I have properly informed my parents or the person(s) exercising parental authority over
my person of nature of the activity which I am joining and had secured their consent for
my participation in the same. I likewise secured their advise on the measures which I am
to undertake for my personal safety and security in relation to my participation in the said
activity:

f.) I hereby agree to waive any responsibility on the part of EVSU in relation to any
untoward incident which may happen to me during the said internship training, unless the
said loss, damage, injury or accident arose from the direct act or gross negligence of
Eastern Visayas State University- Ormoc City Campus.

______________________________________
Signature of Student

______________________________________
Date
 PRACTICUM CONFIRMATION AND ACCEPTANCE

Engr. Ruderico M. Endriano Jr.

Department Head
Engineering Department
Eastern Visayas State University- Ormoc City Campus

Sir:

We are pleased to accommodate your student, _______________________for internship in

our company. The student understands that he/she abides with the institution/company rules
and regulations, specifically on security, discipline, safety and hygiene.

The details of his/her internship are as follows:

Name of Company/Organization: ______________________________________

Unit/Department Assigned: ______________________________________

Unit Location: _______________________________________

Unit Head: _______________________________________

Contact Details: _______________________________________

Start of Practicum: _______________________________________

End of Practicum: _______________________________________

Reporting Time: _______________________________________

To maximize his/her learning and exposure from the Program, we wish to assure you that
he/she:

 Shall be given meaningful tasks, projects and work assignments that will utilize as well
as enhance his/her competencies and skills in _______________________________.
 Shall not be given tasks that are personal in nature and/or tasks that are unrelated to the
discipline;
 Shall not be given work or assigned to work sites that are dangerous or will expose
him/her to any form of risk or harm; and
 Shall be treated in a professional manner.

Very truly yours,

__________________________________
Company Representative’s Signature

__________________________________
Name and Designation

__________________________________
Date
Date of Enrollment: _______________________________
Start of OJT: ____________________________________

STUDENT’S INFORMATION:

NAME: ___________________________________ CONTACT NUMBER: ______________

Program of Study: ___________________________ Email Address: ____________________
Department Chair/ OJT Adviser: ________________________________________________

COMPANY INFORMATION:

NAME OF INSTITUTION/COMPANY: __________________________________________

Contact Number: ____________________________

Address: _____________________________________________________________________

Supervisor: ___________________________________________________________________
E-mail Address: _______________________________________________________________

SUBMISSION CHECKLIST:
1. Cover Page yes _____ no _____
2. Company’s Sketch Map from EVSU yes _____ no _____
3. Registration Form (showing OJT as an enrolled course) yes _____ no _____
4. Signed Training Confirmation and Acceptance Document yes _____ no _____
5. Waiver Form signed by parents or guardian yes _____ no _____
6. Valid Identification Card of Guardian with Signature yes _____ no _____
7. Student’s Waiver Form yes _____ no _____
8. Medical Certificate from Government Health Service yes _____ no _____
9. Memorandum of Agreement yes _____ no _____

NOTE: Incomplete requirements will not be accepted.

 Waiver and Permission Form

This is to certify that I am permitting my son/daughter, _______________________________,

to undergo an internship training program for a total of ____________ hours starting on
_______________________ until ________________________________, at
_________________________________, in partial fulfilment of the requirements for the degree
of Bachelor of Science in Civil Engineering.

My son/daughter understands that he/she should strictly observe the rules and regulations
of __________________________________________ (insert name of institution or company
where the internship training is to be conducted) and Eastern Visayas State University- Ormoc
City Campus, in relation to the said training program and to observe all other regulations that
may be implemented by his/her direct supervisor in relation to the same.
I hereby agree to waive any responsibility on the part of the Eastern Visayas State University-
Ormoc City Campus in relation to any loss, damage, death, injury, accident that may happen to
my son/daughter during the said internship training, unless such loss, damage, injury, accident or
death resulted from the fault or gross negligence of Eastern Visayas State University- Ormoc
City Campus.
I also hereby agree to hold render Eastern Visayas State University- Ormoc City Campus free
and harmless, including its officers, employees or agents, from any liability, suit or claim field or
made by any party for any injury(including death) or damage to property that my son/daughter
may cause due to his/her willful acts, faults or negligence, whether or not the same arises from or
is related to his/her internship training.
I have likewise read the Internship Waiver Form signed by my son/daughter and is fully
agreeable with all the things stated thereon.

_________________________ ____________________ _____________________

Name of Father Signature Date

_________________________ ____________________ _____________________

Name of Mother Signature Date

_________________________ ____________________ _____________________

Name of Guardian Signature Date

Name of Student: ________________________________

Home address: __________________________________
Telephone No.: _________________________________
Mobile No.: ____________________________________