health declaration

Name 姓名 *

First Name

Last Name

Visit Date *

MM

DD

YYYY

Visit Time *

Hour

Minute

Second

AM PM

Declaration 聲明 *

I hereby declare and agree that: 本人申報、聲明及同意如下: I do not have and have not had within 14 days prior to the date of visit any of the common symptoms of Coronavirus Disease 2019 (COVID-19) – such as fever, malaise, dry cough, shortness of breath, nasal congestion, headache, conjunctivitis, sore throat, diarrhoea, loss of taste or smell, skin rash or discolouration of fingers or toes. 本人現時及在到訪日期前14日內並無以下任何2019冠狀病毒病的常見病徵: 包括發燒、乏力、乾咳、呼吸困難、鼻塞、頭痛、結膜炎、喉嚨痛、腹瀉、喪失味覺或嗅覺、皮疹或手指或腳趾變色。 I have not been out of Hong Kong within 14 days prior to the date of visit/ I have been out of Hong Kong within 14 days prior to the date of visit but am exempted by the HKSAR Government from compulsory quarantine. 本人在到訪日期前14日內並無離開香港 / 本人曾在到訪日期前14日內離開香港但獲香港特別行政區政府豁免接受強制檢疫。 I have not been in close contact with any person who has travelled outside Hong Kong within 14 days prior to my date of visit and has not been exempted by the HKSAR government from compulsory quarantine, in particular family members, helpers or drivers. 本人並未曾與本人之到訪日期前14日內曾離開香港而未獲香港特區政府豁免接受強制檢疫的任何人士有密切接觸，尤其是家人、家庭傭工及司機。 I have not been in close contact with any person who is a confirmed or preliminary positive case of COVID-19 infection in Hong Kong or overseas within 14 days prior to the date of visit. 本人並未在到訪日期前14日內，與任何確診或懷疑確診2019冠狀病毒病人士(無論在香港或海外)有密切接觸。 I do not live in a building in which there has been a confirmed case of COVID-19 within 14 days prior to the date of visit as published by the Centre for Health Protection. 本人並未曾在到訪日期前14日內，於衞生防護中心發佈的2019冠狀病毒病確診個案所在的大廈居住。 I am not required to undergo COVID-19 testing pursuant to a compulsory testing notice or direction / I have undergone COVID-19 testing pursuant to a compulsory testing notice or direction and the result is negative. 本人無需按強制檢測公告或指示接受2019冠狀病毒病檢測/ 本人曾經按強制檢測公告或指示接受2019冠狀病毒病檢測而檢測結果為陰性。 If this form is submitted prior to my visit, I should notify the Club of any change in circumstances prior to or at the time of my visit. 如此申報表是於到訪前遞交而之後情況有變，本人應於到訪前或到訪時向會方申報。

I confirm that the above information is accurate to my best knowledge. 本人聲明據本人所知及所信，以上資料均屬正確無誤。