Health Declaration

HEALTH DECLARATION FORM

* Indicates required field

Name *

First

Last

Phone Number *

Email *

Date of Visit *

Q1] Have you travelled overseas in the last 30 days?

YES / NO *

If Yes,

Please Specify *

Q2] Have you come in to close contact with any of the confirmed cases of the COVID-19 virus in the last 30 days?

YES / NO *

Q3] Do you have any the following flu-like symptoms?

Fever

YES / NO *

Cough

Sore Throat

YES / NO *

Runny Nose

YES / NO *

Breathlessness

YES / NO *

Body Aches

YES / NO *

Others, Please Specify

Please Specify *

By submitting the form to Matchday Affairs, I hereby confirm that the above information is accurate to the best of my knowledge.

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