ATHLETE DATA PRIVACY NOTICE AND CONSENT FORM

The Department of Education engages in the collection of personal

information such as the full name, address, age, medical records,
photographs, videos, and contact information of its student athletes.

All personal information collected by the Department shall be

utilized for accounting, auditing, screening, qualifying, performance
monitoring, and other legitimate purposes for the conduct of athletic
meets, sports competitions, practices, and the publication of results of
sports activities and competitions.

All information collected shall be processed, utilized, retained, and

disposed by authorized personnel in accordance with the relevant policies
of the Department on usage, retention, and disposal of its records.

For concerns regarding data collection, access, disclosure,

correction, and other issues, inquiries may be made to the compliance
officer for privacy, (specify school head, schools division superintendent,
regional director) at (specify email address and contact number).

In consideration of the foregoing, I hereby authorize the Department

of Education to collect, use, and process the above-specified personal
information for screening, qualification, participation in athletic activities,
athletic practices and training, and publication of results in athletic
activities and competitions. In the course of my application to participate
in school, division, regional, national, and international activities and
competitions, I hereby authorize the Department of Education to transmit
relevant personal information to authorized Department personnel to
process such application.

I am hereby authorizing the Department of Education to collect,

process, retain, and dispose of my personal information in accordance with
Department policies.

Date: ________________________

_____________________________________
Signature above printed name
Student-athlete

_________________________________ ______________________________
Signature above printed name Signature above printed name
Parent/Guardian Parent/Guardian

Witnessed by:

________________________________
Signature above printed name
Teacher/Coach

CONFIDENTIALITY UNDERTAKING
 I, ( name ), ( designation ) of ( office ),( agency ),
hereby understand that highly confidential information is being collected
and processed from the conduct of the athletic activities and competitions
within the Department of Education. I hereby affirm that I am authorized
and designated to handle and control the said information in confidence.

In this regard, any information gathered and processed will be kept

confidential and will not be disclosed, divulged nor used beyond its
intended purpose. It may not be reproduced in whole, or in part, nor may
any of the information contained therein be disclosed without the prior
notification or consent of the data subject concerned nor of the
Department of Education.

Furthermore, I acknowledge that the illegal and or unauthorized

disclosure or use of information collected and processed shall be subject
to administrative and criminal liability under the law.

___________________________________
SIGNATURE OVER PRINTED NAME

SECURITY CLEARANCE
 I hereby certify that the following personnel indicated below are
authorized to collect, process, retain, and dispose of personal information of
learners in accordance with the Data Privacy processes and policies of the
Department of Education:

TYPES OF PERIOD OF
DOCUMENTS VALIDITY OF
NAME DESIGNATION SIGNATURE
OR PERSONAL SECURITY
INFORMATION CLEARANCE
MARLO FIEL P. SULTAN DSAC
ROLLY TORERO DSAC
RONNEL ABANTE DSAC

All learner records are highly confidential pursuant to the provisions of BP

232 and other relevant laws, rules, and regulations. Only the designated
personnel may handle these personal information within the period of validity of
their security clearance.

NENE R. MERIOLES, CESO V

(Head of School/Division/Regional Office)
Signature above Printed Name

Name of School:________________________
Division: _______________________________
Region: ________________________________