Considering the Provisions of Republic Act 10173 known as the Data Privacy Act of 2012, I

hereby give my consent to:

Please check your response.

Include my child in the On-line Recognition/ Moving Up Ceremony/ Graduation

Ceremony. I allow his/her name, picture, and achievements to be posted on social media
and known in public. With this, I free Jose Rizal Institute from any legal obligations
that may arise from my decision.

Exclude my child in the On-line Recognition/ Moving Up Ceremony/ Graduation

Ceremony. I do not allow his/her name, picture, and achievements to be posted on social
media and known in public. With this, I free Jose Rizal Institute from any legal
obligations that may arise from my decision.

Name of Parent/
Guardian_____________________________________________________________

Signature______________________________ Date
Signed__________________

Name of Child/ Section__________________ Cellphone

No._______________

Note: Kindly send the Accomplished Letter of Consent to your child’s Class Adviser as soon as
possible.

Thank you.