Cruise Ship Health Declaration Application Form
Full Name
Date of Birth
Gender
Male
Female
Other
Prefer not to say
Passport Number
Nationality
Cabin Number
Email Address
Phone Number
Have you experienced any of the following symptoms in the last 14 days?
Fever
Cough
Shortness of Breath
Sore Throat
Other symptoms (please specify)
Have you been in contact with a confirmed COVID-19 case in the last 14 days?
Yes
No
Have you travelled to any country with known outbreaks in past 14 days?
Yes
No
If yes, specify country/countries visited
Pre-existing Medical Conditions
Current Medications
Remarks / Additional Information
I hereby declare that the information given above is true and correct to the best of my knowledge.