PARENTAL CONSENT

Fracxan L Libiran
Student Name: ______________________________________
November 24, 1998
Date of Birth: ________________________
rd
BSHRM
Course: ____________________________ Year and Section: 3 year
__________________

Activity : Restaurant Practicum

Inclusive Dates: April 2017 to May 2017

School/ College: Institute of International Hospitality Management and Tourism

St. Anne College Lucena, Inc., Diversion Rd., Lucena City

External Coordinator : Ms. Felicitas N.Malubay

406 Tengco St. cor Zamora Brgy. San Roque Pasay City

I, the parent or legal guardian of the above named student, agrees to his/ her participation in the
restaurant practicum identified above. Furthermore, I recognize that the Code of Conduct
currently in place in this school will be enforced as part of this activity. I recognize that there may
be certain academic and/ or behavioral requirements for participation in this restaurant
practicum and that all participants must meet these requirements to take part in this activity.

I agree on the program and the processing involved undertaking the preparation and execution
of this restaurant practicum.

I agree that all costs related to this restaurant practicum shall be shouldered by the student-
participant.

Finally, I agree that the above named student is fit and I allow him/her to join this restaurant
practicum based on medical clearance from a physician.

Felomina L Libiran
Parent/ Guardian Name and Signature: _______________________________
Mother
Relationship: ____________________ Date: April 4, 2017
Government Issued Identification Card Number: ________________________

Prk. Bagong Pag-sa Brgy Ibabang Dupay Red-V Lucena City

Home Address: _________________________________________________
______________________________________________________________
N/A
Telephone: ______________________ 09487536500
Cell Phone: ___________________

Notarization Section:

On this 4th day of April before me, the undersigned notary public, personally appeared
________________________________________________________ (name of document
signer), proved to me through satisfactory evidence of identification , to be the person whose
name is signed above, and swore or affirmed to me that the contents of the document are
truthful and accurate to the best of his/her knowledge and belief.

Signature of Notary Public

Notary Seal