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
student 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, (MYLENE M.
DIMACULANGAN(school head),DR. JOSILYN S. SOLANACESO V (schools division
superintendent),DR. DIOSDADO M. SAN ANTONIO(regional director) at
rosa.reyes@deped.gov.ph 501-1943.

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: __AUGUST 17, 2018________

__MATTHEW T. CARPIO_
Signature above printed name
Student-athlete

__MARIO L. CARPIO ____ ____ROWENA T. CARPIO____

Signature above printed name Signature above printed name
Parent/Guardian Parent/Guardian

Witnessed by:

____MARLENE C. ECHON____
Signature above printed name
Teacher/Coach