Coronavirus (COVID-19) Declaration

Name:: First Name:
Last Name:
I acknowledge that:: I/We have not returned from overseas in the past 14 daysI/We am not required to be in self-isolation/self-quarantineI/We have not previously been diagnosed with COVID-19To 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 pI/We have not been in a COVID-19 hotspot (as defined by the Chief Health Officer) in the past 14 daysI/We have not had a fever, cough, sore throat, shortness of breath or other cold/flu-like symptoms in the last 72 hours and are otherwise well
Phone Number:
Email Address:
Person 1:: First Name:
Last Name:
Person 2:: First Name:
Last Name:
Person 3:: First Name:
Last Name:
Person 4:: First Name:
Last Name:
Person 5:: First Name:
Last Name:
Person 6:: First Name:
Last Name:
Signature:
Date Of Declaration:

42-58 Brunswick Street,
Lismore