Name

First Name Last Name

Date

By signing this form, I declare that the information I have given is true, complete, and correct. I understand that the failure to answer any questions or giving a false answer can be penalized in accordance with the law and will be considered as grounds for my removal to the Iskolar ni Juan program.

Do you have any of the following symptoms?

I do not have any of the symptoms stated above

Yes No

Signature

Clear

Daily Symptoms Checklist