J.H.

CERILLES STATE COLLEGE

Mati, San Miguel, Zamboanga Del Sur
SPF-GUI-04
Issue No. 01
GUIDANCE & COUNSELING OFFICE
STUDENT PROFILE FORM

Data Privacy Notice

The J. H. Cerilles State College (JHCSC) respects your right to privacy and is committed to protect the confidentiality of your
personal information and thus, has adapted the necessary measures to secure it. JHCSC is bound to comply with the Data
Privacy Act of 2012 (RA 10173), its implementing Rules and Regulations and relevant issuance of National Privacy
Commission.
By filling out this form, you are consenting to our collection of your information in accordance with this privacy notice.

I Consent
Signature Date

Please Check: New student ( ), Old student ( ), Returnee ( ), Transferee ( )

A. PERSONAL INFORMATION
Name: __________________________________ Year/Course: _______________Age: _____Contact No.: ______________
(Family Name) (First Name) (M.I)
Gender: _____ Nickname: _________ Civil Status: _______ Religion: ___________Date of Birth___________________
Place of Birth: _______________________________________________Email Address:_______________________________
Home Address: ________________________________________________Youth (16-25) Non-Youth (26-60)

________________________________________________________________________________________________________
(Street/Purok) (Barangay) (Municipality/City) (Province)
Name of Boarding House/Landlady/Landlord: ____________________________ Address: _________________________
(Write N/A if not applicable)

_______________________________
Signature Over Printed Name

Date: ______________________