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 and dental records, photographs, Learner Reference Number, school
records, parental information, and contact information of its 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, school 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