Full name

Address

Mobile number

Email address

Do you had any symptoms of illness such as cough, shortness of breath or difficulty breathing, fever, chills, muscle pain, headache, sore throat, or new loss of taste or smell?

Yes

No

Have you been in close contact with a person who is positive for COVID-19?

Yes

No

Have you or anyone in the family (household) been tested for Coronavirus/COVID-19 and are waiting for results?

Yes

No

Have you or any member(s) of your household travelled by sea or by air, internationally within the past 30 days.

Yes

No

I agree to practise the recommended guidelines for social distancing as much as possible to limit my exposure to the Coronavirus/COVID-19

Yes

No

I further acknowledge that Somerville House can not guarantee that I will not become infected with the Coronavirus/COVID-19.

Yes

No

I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others attending this event.

Yes

No

I agree to inform Somerville House if I or anyone I have been in contact with requires testing for Coronavirus/COVID-19 14 days after the event.

Yes

No

I agree for Somerville House to keep my details as per Queensland Government regulations for 56 days.

Yes

No