Name*

First Name Middle Name Last Name

TUD Facility to Access:

Mobile number*

Email*

example@example.com

Nationality*

Sex*

Male Female

Birth Date*

Format: DD Mmm YYYY

Present Address*

Foreign countries you have worked, visited, transited in the past 14 days*

Enter 'None' if not applicable. Please separate countries with a comma ( , )

Cities in the Philippines you have worked, lived or transited in the past 14 days*

Enter 'None' if not applicable. Please separate countries with a comma ( , )

Have you been sick in the past 30 days?*

Yes No

If Yes, please describe your condition and what hospital did you visit, if any?*

In the last 14 days, did you have any of the following: fever, colds, cough, sore throat, loss of smell and taste, muscle pain, headache or difficulty in breathing?*

Yes No

If Yes, please specify these

In the last 14 days, have you been in close contact or exposed to any person suspected of or confirmed with COVID-19?*

Yes No

If Yes, please describe the circumstances*

In the last 14 days, have you been in close contact with farm animals or exposed to wild animals?*

Yes No

If Yes, please describe the circumstances*

Declaration and Data Privacy Consent Form:

By signing this form, I declare that the information I have given is true, correct, and complete. I understand that failure to answer any question or giving a false answer can be penalized in accordance with law.

I also voluntarily and freely consent to the collection and sharing of the above personal information only in relation to The Upper Deck Lifestyle and Leisure Corporation's compliance to Republic of the Philippines COVID-19 business operation requirements and in accordance with the Data Privacy Act. For any concerns, you may contact tudsportscenter@gmail.com.

Name

First Name Last Name

Date*

Date Hour Minutes AM/PM Option

Signature*

Clear

Health Declaration Form