COVID-19 Guest Declaration

COVID-19 GUEST DECLARATION
In the interest of protecting the health and well-being of our guests and staff, prior to you entering Midland Holiday Park we are required to ask you questions related to your travel and health activities.

We ask that you are honest and take your share of responsibility when responding to the following questions, so that we can all do our best to prevent the spread of COVID-19 in the park and our community.

Due to the Victorian government’s COVID-19 Restricted Activity Directions, please read and complete the following acknowledgements.
NOTE: You may include other members of your group on this form provided that they share the same residence as you and stayed at the same location last night. Otherwise, each individual must submit their own form.
During my stay:*
I am staying in accommodation with self-contained toilet, shower and cooking facilities.I am staying in accommodation without toilet and shower facilities.I am a day visitor.
Name*
I acknowledge that:*
I/We have not returned from overseas in the past 14 days.I/We am not required to be in self-isolation/self-quarantine.I/We have not previously been diagnosed with COVID-19.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 been in a COVID-19 hotspot (as defined by the Chief Health Officer) in the past 14 days.I/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.
If you are unable to acknowledge any of these questions you may be referred to a local health authority or the police.
Contact Details
Phone Number*
Include area code for fixed line phone numbers
Email*
example@example.com
Address Last Stayed*
Street Address
Street Address Line 2
Town/SuburbState
Post Code
Listed Parties
Please list the full names of ALL people covered by this declaration. Only include people that you normally reside with and who you are confident satisfy the above acknowledgements. People who reside in a different location to yourself must complete their own declaration. *
I/We agree to comply with all social distancing measures, good hygiene practices and park rules.
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.
Signature*
Clear
Date*
DayMonthYear
Date
Should be Empty: