FA – 53

August 22, 2018

Rev. 0

NAMEI POLYTECHNIC INSTITUTE

123 A. Mabini St. J-Rizal, Mandaluyong City

DATA PRIVACY CONSENT FORM

STUDENT’S NAME: STUDENT NO.:

COURSE:

In accordance with R.A. 10173 or Data Privacy Act of 2012, I consent to the following terms and
conditions on the collection, use, processing and disclosure of my personal data:

1. I am fully aware that NAMEI Polytechnic Institute has collected and stored my personal
data upon admission. These data includes information about my personal identity,
academics, medical conditions or any documents containing my identity. This includes but
not limited to my name, address, contact number, names of my parents/guardians, date
of birth, grades, disciplinary records, and other information necessary for basic
administration and instruction.
2. I express my consent to NAMEI Polytechnic Institute to collect, use, record, disclose,
transfer, store, organize, update, monitor and/or process my personal information
3. I am fully aware that NAMEI Polytechnic Institute may share such information to affiliated
or partner organizations as part of its contractual obligations, or with government
agencies pursuant to law or legal processes and to generate statistics and other data for
improvement of services to students and quality management.
4. I am likewise giving my consent/permission in favor of my parents/guardian or other
authorized representative to access, verify, examine and or inspect my academic and
scholastic records, school fees/accounts in the school, the result of my medical/dental
examination and all matters that relate to my status as a student of NAMEI Polytechnic
Institute.
5. I hereby affirm my right to be informed, object to processing, access and rectify and to
suspend or withdraw my personal data pursuant to the provisions of the R.A. 10173 and
its implementing rules and regulations.

By signing below, I warrant that I have read, understood all of the above provisions, and agreed
with its full implementation.

SIGNATURE OVER PRINTED NAME

DATE