Scribd
Upload
2 views

Declaration

The document is a participant declaration form that collects personal information, COVID-19 status, vaccination details, and health conditions that may affect participation in an activity. It also requires emergency contact information and a declaration of the accuracy of the provided information. Participants must sign and date the form to confirm their details are correct.

Uploaded by

golua5003
Copyright
© © All Rights Reserved
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
2 views

Declaration

The document is a participant declaration form that collects personal information, COVID-19 status, vaccination details, and health conditions that may affect participation in an activity. It also requires emergency contact information and a declaration of the accuracy of the provided information. Participants must sign and date the form to confirm their details are correct.

Uploaded by

golua5003
Copyright
© © All Rights Reserved
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
You are on page 1/ 1

PARTICIPANTS DECLARATION

NAME:- __________________________________________________________

MOBILE NO:- _______________________

CTC UPLINE NAME:- _______________________________

HAVE YOU TESTED COVID POSIVE IN LAST 3 MONTHS:- (Y/N) ______________

VACCINATION FIRST DOSE TAKEN:- (Y/N) ______________________________

DATE OF VACCINATION:- ________________________

SUFERRING FROM-

a) Cough:- (Y/N) __________


b) Cold: (Y/N) ____________
c) Fever:- (Y/N) ___________
d) Respiratory Distress:- (Y/N) _________

What physical disabilities or conditions (heart conditions, diabetes, seizures, etc.) do you have that might
affect your participation in this activity including operations illness, broken bones in the past six months?
__________________________________________________________________________________________
____________________________________________________________

PERSON TO CONTACT IN CASE OF EMERGENCY


Emergency Contact Name: _____________________________________________
Relationship: ________________________________________________________
Phone (h) ________________________ (mob)_____________________________

I DELCLARE THAT ALL THE INFORMATION FURNISHED ABOVE ARE CORRECT.

DATE:-

SIGNATURE.

You might also like