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COVID-19 / GROUP HEALTH DECLARATION & CONSENT FORM

During this period of Covid-19 we need to ask everyone to please take a Lateral Flow Test and complete and submit this form THREE days before arrival. All information given is confidential. We look forward to welcoming you to your retreat. Thank you.

Name

First Name

Last Name

COVID-19 VACCINATION

Are you fully vaccinated against Covid-19?

PREVIOUS LATERAL FLOW/PCR TEST

Have you had a positive test result for Covid-19 in the last 14 days, or been asked to self isolate?

COVID-19 SYMPTOMS

Do you presently have, or have you had any symptoms that may indicate you have a Covid-19 infection in the last 14 days (fever, loss of taste and smell, unusual fatigue, shortness of breath etc)?

CONTACT

Do you live with or have been in contact with anyone who is self isolating, may have the virus, or is waiting for or has received a positive virus test result in the last 14 days?

LATERAL FLOW TEST RESULT

I confirm that I have taken my pre-retreat Lateral Flow Test as requested. I also confirm that I will keep a photo of the test result should this be requested at any time.

DECLARATION

I declare that the information above is correct to the best of my knowledge and I will inform the Arrigo Programme immediately if my risk category/health status changes. I also agree to my temperature being taken on arrival and taking a Lateral Flow Test if requested. Please enter your full name below as a signature of your declaration.

CONSENT TO RISK

I understand and accept the risks of Covid-19 and accept responsibility in agreeing to attend and partake in personal sessions, knowing that the Arrigo Programme cannot be held accountable or liable at any time for any Covid-19 infection that I may or may not experience, during or after my attendance. Please enter your full name below as a signature of your consent.

COVID-19 / GROUP HEALTH DECLARATION & CONSENT FORM

for information and bookings please call 07732 914647

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