Country Club, Inc. Acacia Avenue, Village City P.O. Box #352 Tel Nos. (02) 823531 to 39, Smart +639985879424, Globe +639176569412 Email : [email protected]

COVID -19 HEALTH DECLARATION FORM

Name : ______Gender: ______Age: ______

Address : ______Contact Number : ______Yes No 1. Have you travelled anywhere outside of the country during the past twenty (20) days? If Yes, pls. indicate date and place ______

2. Have you travelled to any other area in NCR aside from your home town/city in the last twenty (20) days? If Yes, pls. indicate date and place ______

3. In the past fourteen (14) days, Have you experienced any of the symptoms like colds, fever, flu, throat irritation, digestion problem or difficulty in breathing? If Yes, pls. indicate ______

4. Have you undergone any medical consultation or hospital confinement in the past thirty (30) days? If Yes. Pls. indicate ______

5. In the past twenty (20) days, have you been in close contact with any person suspected to be Covid-19 positive or have visited any place that have positive cases? If Yes, pls. indicate ______

6. Are you residing in a community where there is a confirmed positive case of Covid-19?

I hereby certify that the information I have provided above are TRUE, CORRECT AND COMPLETE. I understand that any false/wrong information I have provided may also be a ground for the filing of a criminal complaint against me under Section 9 of Republic Act No. 11332 (or the Mandatory Reporting of Notifiable Diseases and Health Events of Public Health Concern Act) and/or Articles 171 and 172 of the Revised Penal Code of the . By signing and submitting this DECLARATION and providing answers thereto, I confirm that I understood all the contents of this Form and voluntarily waive any claim against Alabang Country Club, Inc., its directors, officers, staff and agents and hold them free from any claim or liability arising from or relating to possible exposure to COVID-19 due to my entry to any part of Alabang Country Club, Inc.’s premises. I likewise consent to the collection, storing, and processing of any and all information contained in this Questionnaire by Alabang Country Club, Inc. and/or any of its authorized representatives, as well as to the disclosure of any information contained herein to the members of the Alabang Country Club, Inc. community, Ayala Alabang Village Association, Ayala Alabang, the local and national governments, health professionals, and other relevant third parties pursuant to applicable laws and regulations, including data privacy law and regulations and all those enacted and issued in light of the current COVID-19 pandemic. Furthermore I fully understand and accept that I will be subject to appropriate disciplinary action by the Board of Directors of ACCI if I intentionally provided false information in this COVID-19 Health Declaration Form. Finally, I undertake to pay for all costs, damages and/or liabilities that ACCI may be ordered by any government authority to pay, and the resulting damages (whether pecuniary or non- pecuniary) to ACCI, if my declarations herein are found to be false and/or my actions while on ACCI premises violate any of ACCI’s rules and are deemed to have resulted in ACCI’s violation of government issuances on the COVID-19 pandemic warranting ACCI’s temporary or permanent closure, or ACCI’s payment of any fine, penalty or assessment.

Signature : ______Date : ______