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Health Self-Declaration form

Health Self-Declaration formadmin2021-08-30T15:31:24-04:00

Please fill the form hereunder within 24 hours before joining the yacht.

Crew/Passenger Health Self-Declaration Form

This form should be completed by all persons prior to, or at the time of embarkation on to the ship. It is intended to screen persons for COVID-19 infection and collect other relevant information.

Name of yacht you are embarking on(Required)

Name of person embarking(Required)

First Last

Date of Arrival onboard(Required)

Are you vaccinated against Covid-19?(Required)

Yes

No

Partially

With which vaccine?(Required)

Date of the last shot received(Required)

During the last 14 days, have you tested positive for being infected with the coronavirus (COVID-19)?(Required)

Yes

No

During the last 14 days, have you shown any symptoms associated with the coronavirus (COVID-19), specifically:(Required)

A fever (100.4F/38C or higher), feel feverish

Have chills

A dry cough

Tiredness

Shortness of breath

Aches and pains

Sore throat

Diarrhea

Nausea

Loss or change in taste/smell

Rash

None of the above

In the last 14 days, have you completed a period of self-isolation related to COVID-19)?(Required)

Yes

No

Please explain(Required)

In the last 14 days, have you had close contact with anyone with symptoms of the coronavirus (COVID-19)? (“Close contact” means being at a distance of less than one meter for more than 15 minutes.)(Required)

Yes

No

In the last 14 days, have you maintained good personal hygiene and complied with applicable health protection measures and precautions?(Required)

Yes

No

Do you have any pre-existing health conditions or health concern?(Required)

Please list the countries you have visited in the last 14 days:(Required)

Name of the person filling this form(Required)

First Last

(Parents or legal guardians are to declare on behalf of passengers under 18 years)

Consent(Required)

I confirm that the information provided above is correct to the best of my knowledge.

CAPTCHA

Email