Group/Family Coronavirus Self-Declaration Form

Web Site

To be completed by the individual or lead member for the group

Title 1 *

First Name 1 *

Surname 1 *

Email 1 *

D.O.B 1

Title 2

First Name 2

Surname 2

Email 2

D.O.B 2

Child Title 1

Miss/Master Miss Master

Child First Name 1

Child Surname 1

Email 1

D.B.O 1

Child Title 2

Miss/Master Miss Master

Child Title 3

Miss/Master Miss Master

Child First Name 2

Child First Name 3

Child Surname 2

Child Surname 3

Email 2

Email 3

D.O.B 4

D.O.B 3

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

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)