WAIVER FORM B

(for Professional and Graduate Students)

Name of Approved Activity: PALARONG MEDISINA 2018: SIKLAB

Date and Time: FEBRUARY 25 AND MARCH 4, 2018 ; 7:00 AM – 7:00 PM
Venue/s: ADVENTIST UNIVERSITY OF THE PHILIPPINES – SILANG, CAVITE
Name of Adviser:

This is to certify that I, John Herbie Cipriano Novero , a 1st Year Medicine student from the College of Medicine
with student number 2017-70119 am voluntarily participating in the Palarong Medisina 2018: SIKLAB, on
February 25 and March 4, 2018 from 7:00 AM to 7:00 PM at the Adventist University of the Philippines, Silang,
Cavite.

I voluntarily and knowingly waive all rights and causes of actions against Pamantasan ng Lungsod ng Maynila, its
faculty members, employees, officials, and administrators, except for liabilities arising from injuries and
damages caused by gross negligence on the part of the university.

I further certify that I am voluntarily contributing N/A for the said undertaking.

In case of emergency, please contact:

Name of Contact Person: Hermingildo P. Novero

Relationship to Student: Father_____________
Contact Number/s: 09196304912________

____________________________
Signature over Printed Name
Date:______________

Attachments:
 Copy of student’s PLM identification card

To be accomplished by Adviser:
Received by:

Date and Time Received: