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