Covid-19 Self Declaration Form

Arrival Date*

Departure Date*

Main Guest Full Name*

Contact Number*

Email*

Address*

How many ADULTS will be staying at Little Cove Court?*

How many CHILDREN will be staying at Little Cove Court?*

Please list each guest name (please include their first and last names)*

Are any guests experiencing any of the following symptoms: Loss of Smell, loss of taste, cough sore throat, fatigue, aches and pains, shortness of breath, runny or stuffy nose, headaches or raised temperature*

Yes
No

Please list the guest name/s and details of those experiencing these symptoms

Has any guest returned from travel outside of Queensland in the past 14 days?*

Yes
No

Please list the guest name/s and provide more details of the situation

Has any guest been in close contact with a person who has returned to Australia in the last 14 days or potential contact with someone that is suspected to have COVID-19?*

Yes
No

Please list the guest name/s and provide more details of the situation

Has any guest been exposed to anyone that is suspected or confirmed to have COVID-19?*

Yes
No

Please list the guest name/s and provide more details of the situation

Declaration*

I hereby declare that the details furnished above are true and correct to the best of my knowledge and belief and I undertake to inform you of any changes therein, immediately. I understand further that I will advise Little Cove Court if any of my guests show symptoms or are diagnosed with Covid 19 following your departure.

Yes
No

Full Name*

Dated*

Contact

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Covid-19 Self Declaration Form

COVID-19 Self Declaration Form for Guests