Republic of the Philippines

DEPARTMENT OF EDUCATION
REGION III – CENTRAL LUZON
SCHOOLS DIVISION OF SAN JOSE DEL MONTE CITY
SAN JOSE DEL MONTE HEIGHTS HIGH SCHOOL
CITY OF SAN JOSE DEL MONTE, BULACAN

ONLINE CONSENT FORM

I hereby consent San Jose del Monte Heights High School’s collection, use, and/or disclosure of
information about my child (screenshot of online classes which captures the learner’s picture and
name, screenshot of learner’s output and participation in the class) made through Online Class video
conferencing and recording applications and other manual and/or electronic procedures utilized
within the course of instruction.

I understand that my child is enrolled and participating in the Online academic setting, and that the
Information collected is part of the remote classroom experienced being utilized and as part of
Means of Verifications of online teaching and learning process.

I understand that my child’s name, image, likeness, speech, their type or written content, their
academic performances may be transmitted during the video potions of remote learning and online
instruction.

The information is meant solely for educational, class, instructional, and school related use only.

Learner’s Name: __________________________________________________

Parent/ Guardian’s Name: __________________________________________

Parent/ Guardian’s Consent, please select only ONE and affix your signature.

________________________ I consent to my child’s information being recorded and use for the
purpose and during the course the entire online instruction of the whole academic year 2021-2022.

________________________ I do not consent to my child’s information being recorded and use for
the purpose and during the course the entire online instruction of the whole academic year 2021-
2022.

Address: San Jose Heights, Muzon, City of San Jose del Monte, Bulacan
Email Address: 307513.sjdmc@deped.gov.ph