Republic of the Philippines

Department of Education
REGION X
SCHOOLS DIVISION OF OROQUIETA CITY

CALL FOR LEARNING RESOURCE INNOVATION ON STORYBOOK AND

VIDEO LESSONS
Official Entry Form for Storybook Writers, Illustrators and Video Developers
PERSONAL INFORMATION AND ASSIGNMENT OF RIGHTS
INNOVATOR’S NAME: _________________________________________________________
Surname Firstname Middle Initial
Age and Date of Birth: _______________________ Gender: ________ Civil Status: _______
Place of Birth: _____________________________________________________________________

Contact Information STORYBOOKS SUBMITTED

Contact Number: _________________________ Title Grade Level

Address: _________________________________ 1. _____________________ _______
Email: ___________________________________
_____________________
Name of School: __________________________ 2. _____________________ _______
___________________________________________ _____________________
Address of School: ________________________
___________________________________________ 3. _____________________ _______
District: ___________________________________ _____________________
Position/Designation: _____________________
Assigned Grade Level: _____________________
Name of Principal: _________________________
Contact Number of School Head or Principal: ______________________________

I solemnly swear on my honor that the stories/videos submitted are my original creations
and are not imitated from any existing learning resources in any government, non-
government, private, and commercial institutions. I am fully aware of the consequences and
penalties that may be imposed upon me should this material be proven plagiarized, copied
or imitated, or infringing copyright of existing authors pursuant to existing laws, rules and
regulations. I therefore affix my signature and that of my immediate supervisor to attest to
the accuracy and truthfulness of this entry form.

I declare that I have read and have accepted the rules of this Competition. I hereby grant
the Department of Education – Oroquieta City Division the exclusive right to exercise
copyright and other intellectual property rights, including storage, derivation and
distribution, provided that I be perpetually listed as the main creator of the Work.

Signed this ____ day of _______, 2021.

_______________________________ _______________________________________
Printed Name and Signature of the Writer/Illustrator Printed Name and Signature of the Immediate Head
/Video Developers

Address : Osilao St., Poblacion 1, Oroquieta City

Telefax Number : (088) – 531-0831
Website : http://depedoroquieta.com/