Health Declaration Form – Valle Verde Country Club Inc

Please fill-up this form as required by the Philippine Government that will require you to declare any illness and provide information that will aid in contact tracing, should the need arise. Be sure that the information you give us is accurate and complete. All the information submitted shall be encrypted, and strictly used only in compliance with Philippine law, guidelines, and ordinances, in relation to business operation in light of COVID-19 response.

Temperature Check

I am a

Member Guest

I am going to

First Name

Last Name

Contact Number

Email Address

Foreign countries you have worked, visited, transited in the past 14 days

Enter 'None' if not applicable. Please separate countries with a comma ( , )

Cities in the Philippines you have worked, lived or transited in the past 14 days

Enter 'None' if not applicable. Please separate countries with a comma ( , )

Have you been sick in the past 30 days?

Yes No

In the last 14 days, did you have any of the following: fever, colds, cough, sore throat, loss of smell and taste, muscle pain, headache or difficulty in breathing?

Yes No

In the last 14 days, have you been in close contact or exposed to any person suspected of or confirmed with COVID-19?

Yes No

In the last 14 days, have you been in close contact withfarm animals or exposed to wild animals?

Yes No

Declaration and Data Privacy Consent Form:

By signing this form, I declare that the information I have given is true, correct, and complete. I understand that failure to answer any question or giving a false answer can be penalized in accordance with the law.

I also voluntarily and freely consent to the collection and sharing of the above personal information only in relation to Valle Verde Country Club Inc's compliance to the Republic of the Philippines COVID-19 business operation requirements and in accordance with the Data Privacy Act. For any concerns, you may contact inquire@valleverdecountryclub.com.

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