Family Adoption Travel Health Declaration Form
Family Name
Adoption Agency
Contact Number
Travel Destination
Travel Dates
Family Members
List Names & Relationships
Health Declaration
Have any family member experienced symptoms such as fever, cough, or difficulty breathing in the past 14 days?
No
Yes
If yes, please specify who and describe their symptoms:
Have any family member tested positive for any contagious illness in the past month?
No
Yes
If yes, provide details:
Does any family member require medication or have ongoing medical conditions?
No
Yes
If yes, please provide details:
Declaration
Signature
Date