I hereby agree to the collection and use of my personal information for the purposes of [insert purpose, e.g., program application, event registration, etc.].

Items Collected: Name, contact information, email address, [add other items as needed]
Purpose of Collection: [e.g., identification, communication regarding the program/event, etc.]
Retention Period: Until the purpose of collection is fulfilled or as required by law.

I understand that I have the right to refuse consent, and in such cases, participation in the relevant service or program may be restricted.