San Juan City Government

Right to Care Application Form

Section 1: Applicant Information

Last Name *

First Name *

Middle Name

Date of birth *

Sex/ Gender Identity *

Civil Status *

Home Address - Street *

Barangay *

City *

Nationality * (Check if foreigner/Not Filipino )

Contact No *

Email Address *

Valid Government ID Type: *

Valid Government ID Number: *

Section 2: Partner / Designated Person Information

This is the person granted the right to make medical decisions

Last Name *

First Name *

Middle Name

Date of birth *

Relationship to Applicant (e.g partner,companion) *

Contact No *

Home Address *

Email Address *

Valid Government ID Type: *

Valid Government ID Number: *

Section 3: Data Privacy Consent

All personal information provided in this Right to Care Card Application shall be processed in accordance with Republic Act No. 10173 and its implementing rules and regulations. The data collected shall be used solely for verification, documentation, and program implementation purposes, and shall be treated with strict confidentiality and protected against unauthorized access.

* I hereby give my consent to the collection, processing, and storage of my personal data for lawful purposes related to this application/program. I understand that my information will be handled in accordance with applicable data privacy laws and will not be shared with unauthorized parties.