Coronavirus Self-Declaration Form

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To be completed by the individual.

Title *

First Name *

Surname *

Email *

D.O.B 1

Address 1 *

Address 3

Home Tel. No

Course/Sailing Start Date

Duration

Day 2 Day 3 Day 4 Day 5 Day 6 Day Week

Do you or any one in your group have any of the following Flu-like symptoms

Fever (38 Deg C or Higher) *

Yes

No

Cough *

Yes

No

Brethlessness *

Yes

No

Sore Thought *

Yes

No

Have you been double covid vacinated >3weeks *

Select Yes or No Yes No

Date of 2nd Vacination *

Have you had a negative Covid test in the last 72 hours *

Have you had a negative Covid test in the last 72 hours Yes No

Date of Test *

Address 2 *

Post Code *

Mobile Tel. No. *

Emergency Contact Details:-Tel. No. *

Please list the country /cities you or party member has travelled to in the last 14 days prior to arrival at Island Crusing Club *

Have you or any immediate family member come in close contact with a confirmed case of the coronavirus in the last 14 days? *

Yes

No

Lead Person Signature By

Confirmation of Signature *

Select to Confirm signature

Date (DD/MM/YY)