Group/Family Coronavirus Self-Declaration Form Email 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)