RELEASE WAIVER AND QUITCLAIM

That I, ____________________, of legal age, Filipino, single/married/widow/er

and a resident of _____________________________________, have voluntarily joined
the Field Trip organized by the Senior Citizen Association of Barangay Daro, Dumaguete
City on 17 December 2016.

That in case there may be any untoward incident or accident that may happen to
me or to the group, I release, waive and quitclaim from any liability thereof the Senior
Citizen Association of Barangay Daro, Dumaguete City or any of its officers;

That I declare that I have read this document and have fully understood its
contents. I further declare that I voluntarily and willingly executed this Release, Waiver
and Quitclaim with full knowledge of my rights under the law.

IN WITNESS WHEREOF, I have hereunto set my hand this _____________at

Dumaguete City.

_____________________________
Affiant

Signed In The Presence Of:

________________________ ___________________________

ACKNOWLEDGMENT

REPUBLIC OF THE PHILIPPINES..)

PROVINCE OF NEGROS ORIENTAL.)S.S.
CITY OF DUMAGUETE.)

BEFORE ME, a Notary Public for the City of Dumaguete, this _____________
in Dumaguete City, Philippines, personally appeared __________________________
personally known to me to be the same person who executed the foregoing instrument
and acknowledge to me that the same is his free and voluntary act and deed.

WITNESS MY HAND AND SEAL.

Doc. No. ______;

Page No. ______;
Book No. ______;
Series of 2016.