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INTERNSHIP WAIVER
I, KERNELL SONNY J. SALAZAR, of legal age, residing at 418 Narra St., Mahabang Parang, Santa Maria,
Bulacan, and a 4th year student of Bulacan State University, College of Criminal Justice Education, by this
document hereby declare:
1) That as part of our curriculum, I have to undergo Student Internship consisting of 300 hours
outside the confines of the University;
2) That I have chosen Regional Trial Court, Branch 14, City of Malolos, Bulacan as the
appropriate place where to render my Internship;
3) That I understand and agree to abide by the policies and standards of the organization for
which I will be working and that may be implemented by my supervisor and our student
internship coordinator in relation to my training;
4) That the University does not provide health insurance (except student health insurance) and
that I will cover medical services that might be necessary due to accidents, illnesses or
injuries I may face while participating in this internship;
5) That I acknowledge as a student of Bulacan State University I also remain subject to the
University’s disciplinary processes for my conduct on internships organized or facilitated by
the University.
6) That I assume full and sole responsibility for all damages incurred or caused by me arising
out of and in the course of my aforesaid training in the said place;
7) Furthermore, I renounce and waive all claims against Bulacan State University and for any
injury that I may sustain or for any loss that I may suffer, personal or pecuniary, in the
performance of my duties or functions as intern due to my negligence.
IN WITNESS WHEREOF, I have hereunto affixed my signature this 12th day of February, 2018, here
at City of Malolos, Bulacan.
___________________________________________
SIGNATURE OVER PRINTED NAME
CONFIRMATION
That I, SANTIAGO G. SALAZAR (father/mother/guardian), of legal age, Filipino and a resident of 418
Narra St., Mahabang Parang, Santa Maria, Bulacan, after being duly sworn in accordance to the law, hereby
agree and state:
___________________________________________
SIGNATURE OVER PRINTED NAME
SUBSCRIBED and SWORN to me before this 12th day of December 2018, affiant exhibiting his/her
Student ID bearing no. 20014-11128 issued at Bulacan State University, SY 2018-2019 as competent proof of
his/her identity.
___________________________________________
ADMINISTERING OFFICER
DOC. NO.
PAGE NO.
BOOK NO.
SERIES OF ______
BulSU-OP-OSI-16F3
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