NPA Covid 19 Declaration

1

Name* This field is required.

First Name

Last Name

2

Todays Date* This field is required.

Date

3

Personal Phone Number* This field is required.

Area Code

Phone Number

5

Please confirm your wristband number* This field is required.

6

Please indicate what days you will attend?* This field is required.

Sept 15th

Sept 16th

Sept 17th

7

Have you been in contact with any Covid 19 cases in the last 7 days.* This field is required.

YESNO

8

Please upload your Vaccination Cert

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9

Have you been diagnosed with confirmed or suspected Covid-19 infection in the last 14 days?* This field is required.

YESNO

10

As far as you are aware have you been in close contact with a confirmed or suspected case of COVID-19 within the last 14 days? * This field is required.

YESNO

11

Are you awaiting the results of a Covid-19 test?* This field is required.

YESNO

12

Have you been advised by a doctor/HSE to self-isolate or restrict your movements at this time?* This field is required.

YESNO

13

Have you returned to Ireland from another country within the last 14 days?* This field is required.

YESNO

14

If Yes which country and what date did you return?

15

Do you have any of the following symptoms?If the answer is “yes” to any of the questions, please DO NOT ATTEND the Championships.

Fever, Chills, Sweating, Aches

High Temperatures

New Worsening Cough

High Temperature

Breathing difficulties / Shortness of Breath

Loss of taste / smell

Sore Throat / Runny Nose

Vomiting / Diarrhoea

16

I confirm I have responded to the above questions truthfully based on my current situation. I commit to informing the National Ploughing Association immediately and excluding myself from the meeting if my situation changes based on the above questions.

Clear