Health And Travel Declaration

IMPORTANT REMINDER : Kindly complete this health declaration form honestly. Failure to answer or giving false information is punishable in accordance with Philippine laws.

PERSONAL DETAILS:

Last Name *

First Name *

Middle Name *

Sex *

Date of Birth *

Month

Day

Year

Civil Status *

Occupation *

Telephone/Mobile No. *

Email Address *

Nationality *

Address In The Philippines *

Hotel *

HEALTH AND TRAVEL DECLARATION:

1. Have you traveled within or outside the Philippines for the last 14 days? If yes, please indicate details below: *

Yes

Arrival Date *

Month

Day

Year

Port of Origin *

Flight # *

Seat # *

Cities / Countries visited in the last Fourteen (14) days *

Reason *

3. Did you visit any health clinic, hospital or nursing home in the past 14 days? *

Yes

Reason *

4. Have you been in contact with a suspected or confirmed SARS – COV (COVID-19) patient for the past 14 days? *

Yes

Reason *

5. Do you have any family/household members or close friends who have met a person currently having flu-like symptoms (e.g. fever, cough, colds) or respiratory problems? *

Yes

Reason *

6. Have you undertaken any CoVID Test? If YES, kindly provide the following information: *

Yes

Type of Test *

RT-PCR

Rapid Antibody Test

Others, please specify

Type of Test Others, please specify

Date of CoVID Testing *

Month

Day

Year

Result *

Reason *

DATA PRIVACY NOTICE:

The. Summit Hotels, in line with Republic Act 10173 or the Data Privacy Act of 2012, is committed to protect and secure personal information obtained in the performance of its duties. The establishment collects the following personal information relevant in the advancement of protocols and precautionary measures against COVID-19 Acute Respiratory Disease. The collected personal information will be kept/stored and accessed only by authorized personnel and will not be shared with any outside parties unless the disclosure is required by, or in compliance with applicable laws and regulations

DECLARATION AND DATA PRIVACY CONSENT FORM:

I knowingly and voluntarily agree to the terms of this binding Declaration, and in doing so represent the truthfulness and veracity of the above answers. I understand that failure to answer any question or giving false answer can be penalized in accordance with the law. Relative thereto, I voluntarily and freely consent to the processing and collection of personal data only in relation to COVID-19 internal protocols.

Acknowledge *

Leave this field blank

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