5/19/22, 4:05 PM PARENTAL CONSENT FORM (2)

PARENTAL CONSENT FORM

Dear Parents/Guardian, 

We would like to inform you that your son/daughter, currently enrolled in DLSU-D, will participate in
an activity stated in this form which is approved by the Office Student Services (OSS) through the
Student Development and Activities Office (SDAO). Kindly accomplish this form to let us know that
you are giving your son/daughter the consent to join the said activity. Kindly attach a picture file of
your e-signature over a printed name to signify your consent.

Note: There is a possibility that the event will be viewed on social media as part of the documentation
of DLSU-D.

Sincerely yours,

Lasallian Vigilance for Environmental Development (LS VERDE)

DATA PRIVACY STATEMENT

1. DLSU-D, through OSS and SDAO,  respects your right to privacy and is committed to
protect the confidentiality of your personal information. By filling up this form you are
consenting to the collection, processing and use of the information in accordance to
the Data Privacy Act of 2012. 

DLSUD shall only use and retain the said personal information until it serves its
purpose, after which it shall be securely disposed. *

I understand and agree

Event & Participant's Details

Activity: ___SIBOL: Healing with the environment__________________________

Date and Time: ___1:00pm-4:30pm________________________________________

Venue: _____Zoom and Facebook Live_____________________________________

2. Participant's Name (Surname, Name, MI)

(ex: Dela Cruz, Juan A.) *

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5/19/22, 4:05 PM PARENTAL CONSENT FORM (2)

SALGADO, JAN JOSEPH RAINER CHRISTOREY MARIA V.

3. Year and Section

(ex:MKA11) *

MEB31

4. Member of:

(ex: Lasallian Vigilance for Environmental Development. Write NA if not applicable) *

DLSUD Chorale

5. DLSU-D E-mail address:

(ex: jadelacruz@dlsud.edu.ph) *

svj0049@dlsud.edu.ph

Parental/Guardian's Consent

6. This is to inform you that I have given my son/daughter the consent to participate in
the aforementioned activity.

I am aware that there is/are faculty member/s who will accompany the students and
who will take all the necessary precautions to keep them virtually safe and secured.
Nonetheless, given all efforts, reminders, and warnings by accompanying faculty
members and school authorities, I know that fortuitous or unexpected incident(s)
beyond their control may still occur. Hence, I will instruct my son/daughter to observe
care, propriety and safety at all times.

I am aware and giving my consent.

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5/19/22, 4:05 PM PARENTAL CONSENT FORM (2)

7. I also recognize that the recording of school activities are needed in the online
modality being applied in DLSU-D. I also understand that the recordings are for
educational purposes and in accordance with the data privacy and anti-cyberbullying
policies of the University. Thus, I am giving a permission to include my
son's/daughter's name, voice and/or image on video as s/he participates in the said
activity.  *

I understand, recognize and give my permission.

8. Attached is my printed name and signature to signify my consent. I fully understand

that my e-signature will be used for this purpose ONLY.

(Non-anonymous question  ) *

 Signature.pdf

9. Parent's /Guardian's Name: *

DR. ARNEL BANAGA SALGADO

10. Relationship to the Participant *

FATHER

11. I HEREBY CERTIFY that the information provided in this form is complete, true and
correct to the best of my knowledge. *

Yes

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