Health Declaration Form for Epic
We have been closely monitoring the virus outbreak and have decided to take precautionary measures on every subsequent event until further clearance from the authorities to mitigate any risks.

This Health Declaration Form serves as our first step in safeguarding all participants from any contagion in preparation for any in-person events, meetings and activities.

Please make sure you have read and understood the following statements and answer this form truthfully. We trust that you share our concern and will inform us of any of the above responsibly.

𝐅𝐚𝐢𝐥𝐮𝐫𝐞 𝐭𝐨 𝐬𝐢𝐠𝐧 𝐭𝐡𝐞 𝐝𝐞𝐜𝐥𝐚𝐫𝐚𝐭𝐢𝐨𝐧 𝐰𝐢𝐥𝐥 𝐫𝐞𝐬𝐮𝐥𝐭 𝐢𝐧 𝐚𝐧 𝐢𝐧𝐬𝐭𝐚𝐧𝐭 𝐝𝐢𝐬𝐪𝐮𝐚𝐥𝐢𝐟𝐢𝐜𝐚𝐭𝐢𝐨𝐧 𝐨𝐟 𝐲𝐨𝐮𝐫 𝐩𝐚𝐫𝐭𝐢𝐜𝐢𝐩𝐚𝐭𝐢𝐨𝐧.
Sign in to Google to save your progress. Learn more
Email *
Full Name *
Please list the title of the event, meeting or activity you are participating in below. *
Please note that you will not be able to participate in any events, meetings or activities if ...
1. You have returned to Malaysia from overseas within 30 days from the date of event.

(This includes travelers who transit in the mentioned countries regardless of the duration and whether they had cleared immigration in these countries).

2. You have been in contact with any positive Covid-19 patient in the past 20 days.

3. You are unwell or witnessing symptoms such as fever, prolonged sneezing, coughing, fever and shortness of breath or have a temperature of more than 38°C at least 30 days before the event.

4. You do not sign a declaration form prepared by us, stating that you are fully aware and responsible for your well-being.

Please tick if you agree or disagree with the above statements *
Please list if you have attended any large-scale events with more than 50 people in the past 30 days *
Please indicate if you have experienced any of the following symptoms in the past 15 days:
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of EPIC Collective Sdn Bhd. Report Abuse
Google Forms