Eco-Tourism Tubungan, Iloilo

Pre-registration Form

* First Name M.I Last Name Suffix

* Email Address

* Complete Address

* Phone number Date travel * MM-DD-YYYY (Weekend only)

* Destination

Bato Sumpit falls Sitio Baldan /View Deck Bato Simbahan

Mt. Linguob Pinihakan Daraga Others______________________

 HEALTH CHECKLIST
1. Do You have any Travel History? 2. Have you had contact with anyone that you know has
been diagnosed with COVID-19?
NO If YES, where ______________
"Contact is defined as being within 6 feet (2 meters) for more
than 15 minutes with a person, or having direct contact with
infectious fluids from a person with confirmed COVID-19
(for example being coughed or sneezed on)".
3. Have you had a positive-COVID test for active virus in NO YES
the past 10 days?
NO YES

4. Do you have any of these symptoms that you cannot attribute to another condition?
Fever or chill Sore throat

Cough Headache

Shortness of breath or difficulty breathing Fatigue

Muscle or body aches Nausea or vomiting

Recent onset of loss of taste or smell Others___________________

NONE

I hereby authorize LGU Tubungan to collect and process the data indicated herein as part of preventive measure in the control of
the COVID-19 infection. I understand that my personal information is protected by RA 10173, Data Privacy Act of 2012 and that I
am required by RA 11469, Bayanihan to Heal as One, to provide truthful information.

Signature:_______________________________ Date_______________________