COLLEGE HONORS STUDENT CONSENT FORM

I, Blue Austine D. Laureano 202100000114 [Name of student & Student Number], !st year [Year] of
BSHM1A Tertiary Education Department, acknowledges that DLSAU is committed to provide me with the
services pursuant to University’s mission-vision that exudes a culture of excellence while implementing
safeguard to protect my privacy and keep my personal data safe and secure; That its
partners/employees operate and hold personal data under strict confidentiality; That I know my rights
as a Data Subject.

PROCESSING OF PERSONAL DATA

That I will be participating the COLLEGE HONORS ASSEMBLY where the following personal information
are being collected to me with my full consent without expectation of compensation or other
remuneration, now or in the future:

1. use my name; and

2. the video, photograph(s), or reproduction(s) of me, and/or recording of my voice, in part or
in whole, during the event/ activity

PURPOSE OF COLLECTION

That the personal information collected be shared and posted in social media platforms or released
within the university or to any third party with Data Sharing Agreement to protect my personal data for
the following purposes only:

1. To show the College Honors Assembly

2. To promote the DLSAU College Honors Assembly

Now, therefore, I have read this form, understood its contents and HEREBY VOLUNTARILY AND
KNOWINGLY AUTHORIZE the release or share of information orally, in electronic or digital form, or in the
form of written records until written notice of revocation.

IMPORTANT: Duly accomplished/ signed Consent Form must be emailed at ted.honors@dlsau.edu.ph

on or before MAY 27, 2022 (until 5PM only). Late submission will NOT be accommodated.

Blue Austine D. Laureano May 19, 2022

Student’s signature over printed name Date

Blesilda D. Laureano May 19, 2022

Parent’s signature over printed name Date