Travel & Health Declaration Form

In view of COVID-19 situation in Singapore, X-Trekkers is taking precautionary measures by seeking your co-operation to complete the following travel & health declaration. Please indicate if you have/have not travelled outside of Singapore within the past 14 days. If you are feeling unwell or serving Stay Home Notice (SHN)/ taking Leave of Absence (LOA), we will postpone your participation without any penalty. Kindly submit your travel declaration within 2 working days from receipt of this notification. * Required

1. What Event Are You Attending?*

2. Event Start Date*

3. Full Name (as in NRIC/ PASSPORT)*

4. Last 3 digits and 1 letter of NRIC No (SXXXX123A) / FIN No (GXXXX123A) / Passport No (for Foreigners) *

5.1 Phone*

For Contact Tracing

5.2 Email

6.1 Have you travelled outside Singapore within the last 14 days?*

6.2 If "yes" to Question 6.1, please specify the countries and cities that you have visited.

7.1 Have you been issued a Stay Home Notice or taking Leave of Absence in the past 14 days?*

7.2. If yes to Question 7.1, please indicate the period of SHN or LOA <dd/mm/yyyy to dd/mm/yyyy>

8. In the past 14 days, I have come in close contact with someone who is:*

9. Are you feeling unwell currently? (E.g Fever, cough sore throat, runny nose & breathlessness) **

10.1 Are you vaccinated for covid 19?*

10.2 If "Yes" to Question 10.1, when did you have your 2nd Shot?

10.3 If "No" to Question 10.1, do you have a valid negative pre-event test (PET) result for the duration??

Please upload your PET result

Accepted file types: jpg, gif, png, pdf, Max. file size: 10 MB.

(Max size 10MB)

11.1 Have you just recovered from covid 19?*

11.2 If "Yes" to Question 11.1, when did you recover?

I hereby declare that the above information provided is to the best of my knowledge and this is a truthful declaration. (The information you provide is important in managing the risk of COVID-19 transmission. The Infectious Diseases Act requires a person who has reason to suspect that he is a case or carrier of COVID-19, or has had contact with a person with COVID-19, to act in a responsible manner to not expose other persons to the risk of infection by the disease.) **

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No

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