PHILIPPINE SCIENCE HIGH SCHOOL SYSTEM

CAMPUS:

PHOTO AND VIDEO RELEASE FORM

I give permission to to use and publish my photographs

(SIP Agency)

and videos(s) in any and all its publications and in all other media during the Science Immersion Program

(SIP). The photograph(s) and video(s) shall exclude anything related to Intellectual Property (IP) works,

subject to existing IP laws and agreement.

The may use the photograph(s) and videos(s) only

(SIP Agency)

the period of the SIP or not more than 6 months from the beginning of my immersion of SIP at

.
(SIP Agency)

I will make no monetary or other claim against for the use of

(SIP Agency)
the photograph(s) and video(s).

Please check appropriately:

❒ By signing below, I have read and agreed to the terms of this photo and video release dorm.
❒ I do not give permission.

(Printed Name and Signature of Student) Date Campus

As parent or legal guardian, I do hereby give my consent and grant my permission to all of the
foregoing.

(Signature over Printed Name of Mother/Father) (Date Signed)

or

(Signature over Printed Name of Guardian) (Date Signed)

In compliance to the Data Privacy Act of 2012, personal information that includes
photo(s)/video(s) submitted by the student shall only be used for Science Immersion Program
(SIP) purposes, and shall not be shared/ transferred without prior written consent of the PSHS
SYSTEM and the data subject. The SIP participating agency further warrants that measures
are in place to prevent the unauthorized use or disclosure of the personal information
submitted. The PSHS SYSTEM upon the request of the participating agency shall also secure
photo/video release form that would cover documentation photos/videos of the SIP activities
and for PSHS System promotional and educational purpose only.

PSHS-00-F-DSA-23-Ver02-Rev0-12/09/23