Version 5.

0 - January 13, 2024 Annex B - Individual Form

LGBT DAVAO CITY COALITION INC.

Equality for All

INDIVIDUAL MEMBERSHIP FORM

(Official Form)

This form is for Old, New and Transferred Members. Please encode correct details and double check name spelling.

1. PERSONAL INFORMATION
Complete Name: Bargayo George
Last Name Given Name Middle Name Ext. Name
Date of Birth (Month/Date/Year): 01/25/1998 Age: 26 26
Sex: M Gender: Gay
Complete Address Prk. 03, Brgy. Suawan, Marilog Dist. Davao City
Barangay Registered Suawan
Facebook Account (www.facebook.co https://www.facebook.com/devonbargayo.06?mibextid=ZbWKwL
Contact Number/s 9916496290
Email Address andingilvibar@gmail.com
Position in the Organization Member
Employment Status: Employed Blood Type
Present Work Jades Cargo Length of Service in Present Wor New hired
Educational Status: College Graduate
PWD? Yes or No: No Registered to PDAO?
2. EDUCATIONAL BACKGROUND
Highest Educational Attainment Name of School Year
3 years Diploma Graduate Interface Computer College Inc. 2023-2024

NOTE: Please attached any of the following: (1) photocopied any government issued ID cards with Davao City as official
address, (2) For Minors, School ID with Parent Consent and Birth Certificate.
STATEMENT OF INFORMED CONSENT Employment Status: Highest Educational Attainment:
- Full-Time Working Postgraduate
I understand the purpose of this profiling activity. I voluntarily and - Part-Time Working College Graduate
willfully give my consent to be part of this undertaking. I certify that the - Unemployed 4th year College Completer (5th year Course)
information that I will give are true and correct and that any - On the Job Training 3rd year College Completer
misrepresentation and falsification of information may void their - Self-Employed 2nd year College Completer
application to LGBT Davao City Coalition, Inc. as Volunteer. - Not Applicable 1st year College Completer
High School Graduate
I authorize the use, processing and sharing of my personal data for the - Grade 11 moved-up (Senior High)

purpose that is intended for without prejudice to my rights stated in the Educational Status: - Grade 10 moved-up (Junior High)

Data Privacy Act of 2012. - Out-of-School 3rd year HS / Grade 9 moved-up (Junior High)
- In-School 2nd year HS / Grade 8 moved-up (Junior High)
- Not Applicable 1st year HS / Grade 7 moved-up (Junior High)
Elementary Graduate
- Elementary Undergraduate
ALS Passer

TESDA Skilled Qualifier

- Vocational Education Passer

Printed Name Signature

George Bargayo
Feb. 18, 2024
PARENTAL CONSENT (For Minors Only - 17 y.o. and below)

I/We hereby willingly and voluntarily give consent to the participation of my/our __________
(Name) to LGBT Davao City Coalition being an accredit member for the fiscal year 2024.
I/We have considered the benefits that my son or daughter will derive from his participation in the activity provided that due
care,
 diligence and necessary precautions will be observed to ensure his/her health and safety.

Further, I/We authorize LGBT Davao City Coalition to collect, process, retain, and dispose of personal information
of the above-mentioned name in accordance with the Data Privacy Act of 2012.

Name of Father Signature Name of Mother Signature Date Signed

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