Travel Declaration Form

Dear Parents
In order to ensure the continuous wellbeing of your child, their classmates, and the rest of the student and
staff community. As per the current prevention and control policy of COVID-19 (New Coronavirus), Ministry
of Health and Prevention (MOHAP) requires you to provide information regarding your history of travel in the
last 14 days, please report and update regularly in case of travel

Please complete the below form ONLY if your child or close relatives have visited any of the following
countries: China, Hong Kong, South Korea, Iran, Japan, Singapore or Italy. Please make sure to return the
form to the school clinic as soon as your child/ close relative returns from travel from the above mentioned
countries.
Email address *
School Name
Student Name
Grade
Date of Birth
Student history of travel in the last 14days
Clear selection
Close relative history of travel in the last 14 days
Clear selection
Country visited
Date of travel
MM
/
DD
/
YYYY
Duration of Stay
Any history of contact with confirmed COVID-19 case
Clear selection
Fever or flu symptoms during or after return from travel
Clear selection
Contact Number
Other Notes
Clear selection
Parent/Guardian name
Relationship
I hereby declare that the details furnished above are true and correct to the best of my knowledge and belief, and I undertake the responsibility to inform you of any changes therein, immediately.
Date of Declaration
MM
/
DD
/
YYYY
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of India International School. Report Abuse