FM-LPU-OOSA-04/12
Office of Student Affairs/Prefect of Discipline
Tel. No. (043) 723-0706 loc. 166(Main Campus)
Tel. No. (043) 723-0054 loc. 131(LIMA Campus)
Tel. No. (043) 741-5763 loc. 106 (Riverside Campus)
PARENT’S CONSENT
PEMEY DELOS ANGELES
I/We, _________________________________________________________the
(name of parent/s or guardian)
parent/s/guardian of ____________________________________,
JET PATRICK DELOS ANGELES resident of _______
(name of student)
78 RIZAL AVENUE BATS CITY
___________________________________, do hereby voluntarily
and freely allow or give
my/our consent for him/her to join and participate in
Completion
_________________________________ LPU – BATANGAS RIVERSIDE CAMPUS
at _________________________________
(activity/event) (venue)
MAY 24 2024/ 8:00 am – 12:00 pm
to be held on _________________________________, organized/sponsored/facilitated
(date of activity)
HIGH SCHOOL DEPARTMENT
by ________________________________________.
I/We understand that my/our son’s/daughter’s participation in the said activity is
voluntary on his/her own free-will and he/she does so without pressure, intimidation, or
threat of any kind, from anyone or any reason but only of his/her own desire to gain more
learning experience of the said activity. I/We also understand that this activity is in line
with the tri-fold functions of LPU-Batangas, such as instruction, research, community
extension/co-curricular activities, in line with the LPU-B Vision and Mission.
I/We further understand that he/she will abide by the rules, regulations, guidelines
or policies that may be imposed by LYCEUM OF THE PHILIPPINES UNIVERSITY-
BATANGAS (LPU-B) its management, officials, or employees to ensure his/her safety
and general welfare before, during and immediately after the activity. Otherwise, LPU-B,
its management, officials or employees shall not be liable for any untoward incident(s)
arising/resulting from his/her own negligence and/or non-compliance therewith.
PEMEY DELOS ANGELES
Signature over printed name Signature over printed name
(Mother/Guardian) (Father/Guardian)
0998 558 5199
Contact No. ________________________ Contact No. _______________________
Driver’s License
Government Issued ID: _______________ Government Issued ID: ______________
I hereby attest that the signature/s appearing above is/are the signature/s of my parent/s
or guardian/s.
____________________________________
Signature over printed name of student
Valid ID: _____________________________
SUBSCRIBED AND SWORN TO BEFORE ME, this ______________________ at
______________________, affiant/s exhibited to me his/her/their above-described competent
evidence of identity.
Doc. No._____;
Page No._____;
Book No._____;
Series of 20__.
DATA PRIVACY CONSENT
I hereby declare that by signing:
1. I attest that the information I have written is true and correct to
the best of my personal knowledge;
2. I signify my consent to the collection, use, recording, storing,
organizing, consolidation, updating, processing, access to
transfer, disclosure or data sharing of my personal and sensitive
personal information that I provided to LPU-B including its
sister schools/ universities, industry partners, affiliates, external
providers, local and foreign authorities regardless of their
location and/or registration for the purposes for which it was
collected and such other lawful purposes I consent to or as
required or permitted by law;
3. I understand that upon my written request and subject to
designated office hours of the LPU-B, I will be provided with the
reasonable access to my personal information provided to LPU-
B to verify the accuracy and completeness of my information
and request for its amendment, if deemed appropriate, and;
4. I am fully aware that the consent or permission I am giving in
favor of LPU-B shall be effective immediately upon signing of
this form and shall continue unless I revoke the same in writing.
Sixty working days upon receipt of the written revocation, LPU-
B shall immediately cease from performing the acts mentioned
under paragraph 2 herein concerning my personal and sensitive
personal information.
PEMEY DELOS ANGELES
___________________________
Signature over printed name
Date:___________
MAY 24, 2024 __________
