Republic of the Philippines

Bangsamoro Autonomous Region in Muslim MIndanao

Province of Lanao Del Sur
MUNICIPALITY OF PIAGAPO

YOUTH PROFILE FORM

CONSENT FORM

I hereby give my consent to the Sangguniang Kabataan (SK) of Barangay ______________ Municipality of
Piagapo to collect, use, and store all the information I have provided herein for the purpose of Profiling the
Katipunan ng Kabataan (KK) of Barangay _____________ , Municipality of Piagapo amd other legitimate
purposes pursuant to Republic Act No. 10472, also known as Sangguniang Kabataan Reform Act of 2015,
Republic Act No. 10173, also known as Data Privacy Act of 2012, and other statutory acts that may applu.

Do note that the SK cannot utilize any information herein as evidence in any legal proceedings.

Signature over Printed Name Date

PLEASE FILL OUT THIS FORM COMPLETELY.

PERSONAL INFORMATION ID NO._______________

Name

Last Name First Name Middle Name Ext. Jr/Sr.

Age 15-17 y/o 18-24 y/o 25-30 y/o

Civil Status Single Married Others Please specify:____________________

Sex Male Female Religion:

Contact No.: Email Address
Registered Yes No Purok:
Voter
Highest Junior HS Senior HS
Elementary ALS
Educational yy
College Vocational Post-Graduate
Attainment Doctorate
Course:

In School Out-of_School Employed Unemployed

If out-of-school, please indicate the reason:

If working Government Private Self-Employed Duration:

If government, what agency?

OTHER INFORMATION
Do you have disability/ies? No If Yes, Please specify___________________

Do you have medical Condition/s? No If Yes, Please specify___________________

Are you a member of any youth organization?

Yes No
If YES, please specify what organization:

Skills Interests
 Republic of the Philippines
Bangsamoro Autonomous Region in Muslim MIndanao
Province of Lanao Del Sur
Municipality of PIAGAPO

OFFICE OF THE SANGGUNIANG KABATAAN

NINE (9) CENTERS OF PARTICIPATION EXISTING PROBLEMS IN YOUR YOUTH

SUGGESTIONS
AND OTHER AREAS OF CONCERN COMMUNITY

1. Health
Including but not limited to:
 Sport and Development

2. Education
3. Economic Empowerment
4. Social Inclusion and Equity
Including but limited to:
 Gender and Developement

5.Peace Builiding and Security

6.Governance

7. Active Citizemship
Including but not limited to:
 Tourism, Culture & the Art
 Disaster Risk Reduction and
Resiliency

8.Environment

9.Global Mobility

Moral Recovery and Spiritual

Enrichment
Reward and Incentivers

Enumerator:

Signature over Printed Name

….……………………………………………PLEASE DO NOT LOSE THIS SLIP………………………………………………………

ID No:____________ Date:_________________

This slip will serve as your proof of completion and submission of the Youth Profile Form. For any concern
during the Profiling or for any concern in your youth community, you may contact the following.

[1] Sangguniang Kabataan President, HON. AMER-HASSAN S. BAZER ( 0961-737-6801)

[2] LYDO, SAIDALIAH C. AYONAN (0907-242-8225)