MAIN CAMPUS

San Roque, Sogod, Southern Leyte

Email: president@southernleytestateu.edu.ph
Website: www.southernleytestateu.edu.ph

Excellence | Service | Leadership and Good Governance | Innovation | Social Responsibility | Integrity | Professionalism | Spirituality

DATA PRIVACY CONSENT (DPC) FORM

OF STUDENT’S PERSONAL INFORMATION

I, __________________________________, am fully aware that Southern Leyte State University (SLSU) or

its designated representative is duty bound and obligated under the Data Privacy Act of 2012 to
protect all my personal and sensitive information that it collects, processes, uses, and shares
upon my enrollment and stay in the University.

Any data on behalf of my student’s identity, academics, medical conditions, or any documents
containing the same and not limited to the name, address, names of the parents or guardians,
date of birth, grades, attendance, disciplinary records, and others as regards for basic
administration and instruction are considered my student personal information. I understand
that these can be disclosed without my consent if it relates to my enrolment and to be used only
by SLSU _______________Campus to pursue its legitimate interests as an educational institution.
Likewise, I am fully aware that SLSU may share such information to affiliates or partner
organizations as part of its contractual obligations, or with government agencies pursuant to
law or legal processes. In this regard, I hereby allow SLSU to collect, process, use and share my
personal data in the pursuit of its legitimate interests as an educational institution.

By submitting this form, I acknowledge and voluntarily give my consent to have photographs
taken during school organized events/activities. The school may use or share these photographs
with its members and staff for newsletter, email, communications, marketing and/or website
publications, yearbook, and for any other legitimate purpose and intent of the institution.

Furthermore, I expressly give my consent to SLSU to disclose to my parents, guardian and/or

other’s name as specified and check below the foregoing information relative to my education
status-grades, program enrolled and year level, and subjects taken or enrolled.

( ) Father’s Name : _______________________________________

( ) Mother’s Name : _______________________________________
( ) Guardian’s Name : _______________________________________
( ) Other’s Name : _______________________________________ Relationship: _________________________

Student’s Signature : ___________________________________________

Printed Name : ___________________________________________
ID Number : _________________
Date Issued : _________________

Note: If this DPC Form is a computer-generated document and by ticking gives the consent and
no signature of the student is required.

Doc. Code: SLSU-QF-RE14

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Date: 21 February 2022 https://www.youtube.com/c/SouthernLeyteStateUniversity