GUEST REGISTRATION FORM

Control ID No.:

Cottage Name: Simplicity Bungalow Check In Date/Time: May 14, 2021/ 2:00pm

Purpose of Visit: Leisure Check Out Date/Time: May 17, 2021/12:00nn

No Names of Guest Nationality Age

.
1 Jeffrey Dumangas Filipino 28
2 Jocil Dumangas Filipino 29
3 Jaz Shenneah Leigh Dumangas Filipino 4
4 Jyra Shekinah Lee Dumangas Filipino 1
5
6
7
8
9
10
11
12
13
14
15

WAIVER
I, ____JOCIL C. DUMANGAS__________, in my personal capacity and on behalf of my family/ _____________________,
(collectively, the "Guests") hereby acknowledge that we have read and/or have been duly informed about the rules and
regulations of Stilts Calatagan Beach Resort, ("the Resort"). We hereby agree to abide by all of the rules and regulations
of the Resort. Accordingly, we shall be responsible for our own safety and security and shall not leave any minor children
unattended or unsupervised at any time during our stay at the Resort. We shall also not leave any of our valuables
unattended during our stay at the Resort.

In view of the foregoing, each of the Guests hereby releases and holds Herarc Realty Corporation, the owner and
operator of the Resort, and all of its officers, stockholders and employees, free and harmless from any liability
whatsoever in connection with the Guests' stay at the Resort. The scope of this release and waiver shall include, but not
be limited to: a) damages, losses or injuries arising from or relating to the use of the Resort's facilities; b) damages,
losses or injuries arising from or relating to recreational activities which the Guests shall engage in while staying at the
Resort; or c) damages to or losses of any of the Guests' personal belongings, jewelry or other personal property at the
Resort.

JOCIL C. DUMANGAS

Signature over Printed Name

 HEALTH DECLARATION FORM
IMPORTANT REMINDER: Kindly complete this health declaration form honestly. Failure to answer or
giving false information is punishable in accordance with Philippine laws.
PERSONAL INFORMATION:
DUMANGAS JOCIL C.
Name:
(Last) (First) (M.I.)
Sex: [ ] Male [/ ] Female Date of Birth:(dd/mm/yy) 03/05/1992
Civil Status [ ]Single [/ ] Married [ ]Others, pls. specify: _________________________
Occupation: HOUSEWIFE Tel. /Mobile No. 09614489818
Jhocilcatanyag036@gmail.com Address in the NOELS VILL. BRGY. DOLORES
Email: Philippines TAYTAY,RIZAL

TRAVEL HISTORY:
Arrival Date: N/A Port of Origin: N/A
Flight No: N/A Seat No.: N/A
1)
Countries visited for the past fourteen (14) days: 2) N/A
3)
1)
Cities / municipalities in the Philippines visited for
2) N/A
the past fourteen (14) days:
3)

PLEASE CHECK IF YOU HAVE ANY OF THE FOLLOWING AT PRESENT OR DURING THE PAST
FOURTEEN (14) DAYS:
[ ] Fever [ ] Cough [ ] Unexplained Bruising or
[ ] Headache [ ] Difficulty of Breathing Bleeding
[ ] Sore Throat [ ] Body Weakness [ ] Severe Diarrhea
[ ] Others (Specify): _____________________________

HEALTH AND SAFETY- RELATED QUESTIONS Yes No

Did you visit any hospital, clinic, or nursing home in the past fourteen (14) days? /

Have you been in contact with a suspected or confirmed SARS – COV (COVID-19)
/
patient for the past fourteen (14) days?
Do you have any household member/s, or close friend/s who have met a person currently
having fever, cough and/or respiratory problems? /

Data Privacy Notice: The. (name of establishment), in line with Republic Act 10173 or the Data Privacy Act of
2012, is committed to protect and secure personal information obtained in the performance of its duties. The
establishment collects the following personal information relevant in the advancement of protocols and
precautionary measures against COVID-19 Acute Respiratory Disease. The collected personal information will
be kept/stored and accessed only by authorized personnel and will not be shared with any outside parties unless
the disclosure is required by, or in compliance with applicable laws and regulations
Declaration and Data Privacy Consent Form:
I knowingly and voluntarily agree to the terms of this binding Declaration, and in doing so represent the
truthfulness and veracity of the above answers. I understand that failure to answer any question or giving false
answer can be penalized in accordance with the law. Relative thereto, I voluntarily and freely consent to the
processing and collection of personal data only in relation to COVID-19 internal protocols.

_________JOCIL C. DUMANGAS_______ ___May 12, 2021_____

Name and Signature Date

HEALTH DECLARATION FORM

 IMPORTANT REMINDER: Kindly complete this health declaration form honestly. Failure to answer or
giving false information is punishable in accordance with Philippine laws.
PERSONAL INFORMATION:
DUMANGAS JEFFREY D.
Name:
(Last) (First) (M.I.)
Sex: [/ ] Male [ ] Female Date of Birth:(dd/mm/yy) 26/07/1992
Civil Status [ ]Single [ / ] Married [ ]Others, pls. specify: _________________________
Occupation: SOFTWARE ENGINEER Tel. /Mobile No. 09614489818
jeffreydumangas@gmail.com Address in the NOELS VILL. BRGY. DOLORES
Email: Philippines TAYTAY,RIZAL

TRAVEL HISTORY:
Arrival Date: N/A Port of Origin: N/A
Flight No: N/A Seat No.: N/A
1)
Countries visited for the past fourteen (14) days: 2) N/A
3)
1)
Cities / municipalities in the Philippines visited for
2) N/A
the past fourteen (14) days:
3)

PLEASE CHECK IF YOU HAVE ANY OF THE FOLLOWING AT PRESENT OR DURING THE PAST
FOURTEEN (14) DAYS:
[ ] Fever [ ] Cough [ ] Unexplained Bruising or
[ ] Headache [ ] Difficulty of Breathing Bleeding
[ ] Sore Throat [ ] Body Weakness [ ] Severe Diarrhea
[ ] Others (Specify): _____________________________

HEALTH AND SAFETY- RELATED QUESTIONS Yes No

Did you visit any hospital, clinic, or nursing home in the past fourteen (14) days? /

Have you been in contact with a suspected or confirmed SARS – COV (COVID-19)
/
patient for the past fourteen (14) days?
Do you have any household member/s, or close friend/s who have met a person currently
having fever, cough and/or respiratory problems? /

Data Privacy Notice: The. (name of establishment), in line with Republic Act 10173 or the Data Privacy Act of
2012, is committed to protect and secure personal information obtained in the performance of its duties. The
establishment collects the following personal information relevant in the advancement of protocols and
precautionary measures against COVID-19 Acute Respiratory Disease. The collected personal information will
be kept/stored and accessed only by authorized personnel and will not be shared with any outside parties unless
the disclosure is required by, or in compliance with applicable laws and regulations
Declaration and Data Privacy Consent Form:
I knowingly and voluntarily agree to the terms of this binding Declaration, and in doing so represent the
truthfulness and veracity of the above answers. I understand that failure to answer any question or giving false
answer can be penalized in accordance with the law. Relative thereto, I voluntarily and freely consent to the
processing and collection of personal data only in relation to COVID-19 internal protocols.

_________JEFFREY D. DUMANGAS_______ ___May 12, 2021_____

Name and Signature Date

HEALTH DECLARATION FORM

 IMPORTANT REMINDER: Kindly complete this health declaration form honestly. Failure to answer or
giving false information is punishable in accordance with Philippine laws.
PERSONAL INFORMATION:
DUMANGAS JAZ SHENNEAH LEIGH C.
Name:
(Last) (First) (M.I.)
Sex: [ ] Male [/ ] Female Date of Birth:(dd/mm/yy) 31/08/2016
Civil Status [ /]Single [ ] Married [ ]Others, pls. specify: _________________________
Occupation: HOUSEWIFE Tel. /Mobile No. 09614489818
Jhocilcatanyag036@gmail.com Address in the NOELS VILL. BRGY. DOLORES
Email: Philippines TAYTAY,RIZAL

TRAVEL HISTORY:
Arrival Date: N/A Port of Origin: N/A
Flight No: N/A Seat No.: N/A
1)
Countries visited for the past fourteen (14) days: 2) N/A
3)
1)
Cities / municipalities in the Philippines visited for
2) N/A
the past fourteen (14) days:
3)

PLEASE CHECK IF YOU HAVE ANY OF THE FOLLOWING AT PRESENT OR DURING THE PAST
FOURTEEN (14) DAYS:
[ ] Fever [ ] Cough [ ] Unexplained Bruising or
[ ] Headache [ ] Difficulty of Breathing Bleeding
[ ] Sore Throat [ ] Body Weakness [ ] Severe Diarrhea
[ ] Others (Specify): _____________________________

HEALTH AND SAFETY- RELATED QUESTIONS Yes No

Did you visit any hospital, clinic, or nursing home in the past fourteen (14) days? /

Have you been in contact with a suspected or confirmed SARS – COV (COVID-19)
/
patient for the past fourteen (14) days?
Do you have any household member/s, or close friend/s who have met a person currently
having fever, cough and/or respiratory problems? /

Data Privacy Notice: The. (name of establishment), in line with Republic Act 10173 or the Data Privacy Act of
2012, is committed to protect and secure personal information obtained in the performance of its duties. The
establishment collects the following personal information relevant in the advancement of protocols and
precautionary measures against COVID-19 Acute Respiratory Disease. The collected personal information will
be kept/stored and accessed only by authorized personnel and will not be shared with any outside parties unless
the disclosure is required by, or in compliance with applicable laws and regulations
Declaration and Data Privacy Consent Form:
I knowingly and voluntarily agree to the terms of this binding Declaration, and in doing so represent the
truthfulness and veracity of the above answers. I understand that failure to answer any question or giving false
answer can be penalized in accordance with the law. Relative thereto, I voluntarily and freely consent to the
processing and collection of personal data only in relation to COVID-19 internal protocols.

_________JOCIL C. DUMANGAS_______ ___May 12, 2021_____

Name and Signature Date

HEALTH DECLARATION FORM

 IMPORTANT REMINDER: Kindly complete this health declaration form honestly. Failure to answer or
giving false information is punishable in accordance with Philippine laws.
PERSONAL INFORMATION:
DUMANGAS JYRA SHEKINAH LEE C.
Name:
(Last) (First) (M.I.)
Sex: [ ] Male [/ ] Female Date of Birth:(dd/mm/yy) 03/05/1992
Civil Status [ /]Single [ ] Married [ ]Others, pls. specify: _________________________
Occupation: HOUSEWIFE Tel. /Mobile No. 09614489818
Jhocilcatanyag036@gmail.com Address in the NOELS VILL. BRGY. DOLORES
Email: Philippines TAYTAY,RIZAL

TRAVEL HISTORY:
Arrival Date: N/A Port of Origin: N/A
Flight No: N/A Seat No.: N/A
1)
Countries visited for the past fourteen (14) days: 2) N/A
3)
1)
Cities / municipalities in the Philippines visited for
2) N/A
the past fourteen (14) days:
3)

PLEASE CHECK IF YOU HAVE ANY OF THE FOLLOWING AT PRESENT OR DURING THE PAST
FOURTEEN (14) DAYS:
[ ] Fever [ ] Cough [ ] Unexplained Bruising or
[ ] Headache [ ] Difficulty of Breathing Bleeding
[ ] Sore Throat [ ] Body Weakness [ ] Severe Diarrhea
[ ] Others (Specify): _____________________________

HEALTH AND SAFETY- RELATED QUESTIONS Yes No

Did you visit any hospital, clinic, or nursing home in the past fourteen (14) days? /

Have you been in contact with a suspected or confirmed SARS – COV (COVID-19)
/
patient for the past fourteen (14) days?
Do you have any household member/s, or close friend/s who have met a person currently
having fever, cough and/or respiratory problems? /

Data Privacy Notice: The. (name of establishment), in line with Republic Act 10173 or the Data Privacy Act of
2012, is committed to protect and secure personal information obtained in the performance of its duties. The
establishment collects the following personal information relevant in the advancement of protocols and
precautionary measures against COVID-19 Acute Respiratory Disease. The collected personal information will
be kept/stored and accessed only by authorized personnel and will not be shared with any outside parties unless
the disclosure is required by, or in compliance with applicable laws and regulations
Declaration and Data Privacy Consent Form:
I knowingly and voluntarily agree to the terms of this binding Declaration, and in doing so represent the
truthfulness and veracity of the above answers. I understand that failure to answer any question or giving false
answer can be penalized in accordance with the law. Relative thereto, I voluntarily and freely consent to the
processing and collection of personal data only in relation to COVID-19 internal protocols.

_________JOCIL C. DUMANGAS_______ ___May 12, 2021_____

Name and Signature Date