Travel History & Required Information

Your Name*

First Last

Contact no.*

Email*

Do you have history of travel outside Negros Occidental for the past months?*

Yes
No

Please indicate your travel locations outside Negros Occidental:*

Do you have exposure to persons who have history of travel outside Negros Occidental in the past months?*

Yes
No

Do you have exposure to persons who are COVID-19 confirmed / suspects?*

Yes
No

Do you have any of these symptoms?*

Cough
Colds
Sore throat
Body malaise
Fatigue
Fever
Loss of smell and/or taste
Diarrhea
None

Acknowledgment of Information*

I certify that the information provided are true and correct to the best of my knowledge, and I am aware of the consequences of withholding information according to RA 11332 (Law on Reporting of Communicable Diseases), such as but not limited to sanctions or imprisonment.

By submitting this form, I understand that Suntown Camp Foundation may contact me for updates about the event.

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Blood Donation Drive

March 28, 2021 | CICM Mission Center

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