COVID SELF DECLARATION FORM

Your Name

First Name *

Last Name *

Your Address

Address line 1*

Address line 2

City *

County *

Postcode *

Your Email

Your Email Address *

Do you wish to be added to our mailing list? *
YESNO

Your Retreat

Please specify the retreat name*

Your Condition

Have you visited any countries covered in the FCO COVID-19 guidance to travellers (either Category 1 or Category 2)?
YESNO

In the last 15 days, have you had contact with someone who has visited areas affected by the coronavirus and had symptoms such as cough and / or fever? *
YESNO

Please confirm by ticking that you have NOT had any of the following symptoms in the past 15 days? *
Temperature rise above 37.2 degreeCoughBreathlessnessWorsening of general physical conditions

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

I confirm that I am not in the shielded category *
YESNO

I agree to inform Living Saucha if, in the next few days, I find any health problems related to Coronavirus – Covid 19, so that you can carry out further checks with the people I met during our retreat. *
YESNO

Please add todays date *

* Denotes required fields