Name and surname

Email Address

South African ID number

Cell phone number

I HAVE/HAVE NOT tested positive or pre-emptively positive for the Covid-19 virus or been identified as a potential carrier of the Covid-19 virus in the last 14 Days * I HAVE/HAVE NOT tested positive or pre-emptively positive for the Covid-19 virus or been identified as a potential carrier of the Covid-19 virus in the last 14 Days * HAVE NOT HAVE

I do not have any symptoms associated with the Covid-19 virus such as temperatures above 38 degree Celsius, dry cough, tiredness, sore throat, loss of smell and taste, diarrhoea, headaches, shortness of breath etc; * I do not have any symptoms associated with the Covid-19 virus such as temperatures above 38 degree Celsius, dry cough, tiredness, sore throat, loss of smell and taste, diarrhoea, headaches, shortness of breath etc; * DO NOT DO

I HAVE / HAVE NOT been in direct contact with or in the immediate vicinity of any person who has tested positive with the Covid-19 virus or who was diagnosed as possibly being infected by the Covid-19 virus. I HAVE / HAVE NOT been in direct contact with or in the immediate vicinity of any person who has tested positive with the Covid-19 virus or who was diagnosed as possibly being infected by the Covid-19 virus. HAVE NOT HAVE

I HAVE / HAVE NOT recently had a COVID-19 test and am awaiting results I HAVE / HAVE NOT recently had a COVID-19 test and am awaiting results HAVE NOT HAVE

Have you recovered from Covid 19 in the last 6 months Have you recovered from Covid 19 in the last 6 months YES NO

I Hereby declare that the information I have provided about my medical history is accurate to the best of my knowledge. I agree to accept responsibility for any omissions in disclosing my existing or past health conditions. I further agree to wear a protective mask at all times when so directed and to daily screening and furthermore to abide by all instructions by the organization required to help prevent the risk of the transmission of the Covid-19 virus. I agree to contact the COVID officer Andrew Hill (082-5514638) should any of the above conditions change even after the event I Hereby declare that the information I have provided about my medical history is accurate to the best of my knowledge. I agree to accept responsibility for any omissions in disclosing my existing or past health conditions. I further agree to wear a protective mask at all times when so directed and to daily screening and furthermore to abide by all instructions by the organization required to help prevent the risk of the transmission of the Covid-19 virus. I agree to contact the COVID officer Andrew Hill (082-5514638) should any of the above conditions change even after the event Yes