Health Declaration Form

Health Declaration Form

Please fill-up this form as required by River Cities Soccer Club, that will require you to declare any illness and provide information that will aid in contract tracing, should the need arise. Be sure that the information you give is accurate and complete.
Name*

First NameMiddle NameLast Name
MaleFemale
Age*
Contact Number*
Landline or Mobile Number
YesNo
If Yes, please describe your condition and what hospital did you visit, if any?*
YesNo
FeverColdsCoughSore ThroatLoss of Smell and TasteMuscle PainHeadacheDifficulty in Breathing
YesNo
If Yes, please describe the circumstances*
Declaration and Data Privacy Consent Form:

By signing this form, I declare that the information I have given is true, correct, and complete. I understand that failure to answer any question or giving a false answer can be penalized in accordance with law.
Date*

MonthDayYear
Date
Hour MinutesAM/PM Option
Signature*
Should be Empty: