Guest 1 Name (Person completing this form) *

First Name

Last Name

Check-in Date *

MM

DD

YYYY

Acknowledgement *

I/We acknowledge and agree that I/we do not have any reason to believe that I/we are restricted from travelling because of directions or advice given by the relative state Chief Medical Officer and/or the Department of Health in relation to the Covid19 virus; in particular: I/We are not currently under Government directed lockdown/stay-at-home orders, and/or have not been directed to self-isolate I/We are not waiting on COVID-19 test results To the best of my knowledge, I/We have not been in close contact with a person who has a reported or suspected case of coronavirus COVID-19 in the past 14 days I/We have not had flu-like symptoms in the last 72 hours and are otherwise well If you are unable to give this declaration today, please speak to our staff immediately as we will need to take precautionary measures. Self-declaration records will be used and disclosed for managing site access during the risk period and as required by law. Records will be kept securely and retained for the period required under our privacy law obligations. Please let us know if you have any questions and thank you for your co-operation and understanding.

I declare that the answers I have provided above are true and accurate for myself and all the listed parties who are residing with me.

Guest 2 Name

First Name

Last Name

Guest 3 Name

First Name

Last Name

Guest 4 Name

First Name

Last Name

Guest 5 Name

First Name

Last Name

Guest 6 Name

First Name

Last Name