SULTAN KUDARAT STATE UNIVERSITY

ACCESS, EJC Montilla, Tacurong City

__________________ Campus

PERSONAL INFORMATION SHEET

Last Name: ________________ First Name: _____ ____________ Middle Name: ________________Ext’n Name_____

LRN Number: ________________ Email Address: __________ ______________ Contact Number: __________________

Birth date: ________________________ Birthplace: ____________________________________________________________

Gender____ ___ Civil Status:__ _____ Religion: _______ ____Blood type: ___ _
Nationality: _____ _____ Tribal Affiliation:_______________
Address:
Street: ____________Barangay:____________________Municipality:____________________Province:______________
Legal Guardian’s Name:_____________________________ Contact Number of Guardian_________________________
Address of Guardian: _________________________________________________________________________________
4Ps household ID No.:_________________ Listahan ID no.:________________ Household income: ______________
Total no. of Dependents: ___________

Secondary Education (for FRESHMEN only)

Name of school: _____________________________________________________________________________________
Address of School: ___________________________________________________________________________________
School last attended (for TRANSFEREES, DIT, LAW and GRADUATE SCHOOL only)
Name of School: _____________________________________________________________________________________
Address of School: ___________________________________________________________________________________

Note:
Indicate your signature within the box. Do
not overlap over the border.

PLEASE READ AND SIGN THE PRIVACY WAIVER

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SULTAN KUDARAT STATE UNIVERSITY

Office of the University/Campus Registrar
__________________Campus

DATA PRIVACY CONSENT FORM

I, ______________________ _ completely aware that SKSU values the confidentiality of personal information data to comply with the
Data Privacy Act of 2012 in order to protect my right to Data Privacy on my personal information which includes but not limited to my name,
address, names of my parents or guardians, date and place of birth, grades, attendance, and other information essential for basic administration of
instruction.
I know that my personal information cannot be disclosed without my consent. I understand that the information that was collected and processed
related to my enrolment will be used by SKSU to monitor its legitimate interests as an educational institution. Similarly, I am fully aware that SKSU
may share such information to affiliated organizations as part of its obligations, or with government agencies pursuant to law or legal processes. In
this respect, I hereby allow SKSU to collect, process, use and share my personal data in the pursuit of its authentic interests as a learning institution.
In addition, I am giving my consent in favor of my parents/guardian or representative to access, scrutinize and or check my academic and scholastic
records, school accounts in the University, and all matters related to my status as a student of the University.
Lastly, should I commit any misbehavior or should there be a complaint filed against me by reason of violation of the provisions of the Student
Manual or any laws or ordinances, I hereby authorize and give my full consent in favor of the University to inform my parents, guardian, or
representative.

____________________________________ ________________________
Printed Name and Signature of student Date