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AFFIDAVIT

On the Non-existence of symptoms of viral infectious disease

Until further notice, the below affidavit form must be completed before participation in any 1st The Hague Scout Group event or meeting. Participation in a meeting/event will only be permitted if a completed form has been submitted prior to the meeting/event. All persons (Beavers, Cubs, Scouts, Explorers, Leaders and Adult helpers) wishing to participate must submit a form.

The form is for one participant only. If you have multiple participants attending a meeting/event, a separate form must be submitted for each participant.

The form is for a single meeting/event only. If the participant is attending multiple meetings/events, a separate form must be submitted for each meeting/event.

Completed forms must be submitted at least 24 hours before the event but no more than 48 hours before the event.

If you have any issues with the below form, you can download and complete a PDF version. The completed version should be sent to the leader arranging the event.

Affidavit form

Details of meeting/event
Participant's details
Signatory's details (when different to participant)
Declaration
I declare that the above named participant:
is free of all COVID-19 / Corona virus symptoms as detailed below (See More Information)
does not fall into a high risk of a known COVID-19 health problem (kidney, heart, circulation, or respiratory problem, as detailed below (Symptoms and risk factors)
does not share a home with, or come into regular contact with, high risk vulnerable individuals,
is familiar with, careful of, and will maintain the necessary hygiene and social distancing measures,
has NOT, to the best of my knowledge, been in contact with any person suffering from, or suspected of suffering from, a viral disease for a period of 10 days prior to the meeting/event detailed above,
has NOT, within the last 10 days, returned from an international region outside the Netherlands that requires self-isolation (See More Information),
and I will notify the 1st Hague Scout Group if the participant or any family member develops COVID-19 symptoms within 10 days after the meeting/event date detailed above.
In addition, I accept that failing to check any of the above declarations may result in the exclusion of the participant from the meeting/event.


Symptoms indicating possible infection

  • Cold
  • Runny nose
  • Sneezing
  • Sore throat
  • Mild cough
  • Body temperature of 38 °C or greater
  • Sudden loss of smell or taste
 

People with high risk factors

A person is deemed at high risk if he/she, or any person living in the same household, meets at least one of the following risk factors, as specified by The Ministry of Health:
  • Age over 65 years with associated chronic diseases.
  • Chronic lung disease (includes moderate and severe bronchial asthma) with long-term systemic pharmacological treatment.
  • Heart diseases and/or diseases of large blood vessels with long-term systemic pharmacological treatment, e.g. hypertension.
  • Disorder of the immune system, e.g.
    • during immunosuppressive treatment (steroids, HIV, etc.),
    • in anticancer treatment,
    • after transplantation of solid organs and/or bone marrow,
  • Severe obesity (BMI over 40 kg/m2).
  • Pharmacologically treated diabetes mellitus.
  • Chronic kidney disease requiring temporary or permanent support / replacement of kidney function (dialysis).
  • Liver disease (primary or secondary).


Travelling from countries outside the NL

The Netherlands and the other Schengen countries, as well as the United Kingdom, have closed their external borders to people from outside the EU whose journey is not essential. Persons are not permitted to attend any 1st Hague meeting/event until the completion of a period of self-quarantine for 10 days after arrival in the Netherlands from these countries. More information can be found here.


 

NOTE: If you have not been able to check all of the above declarations DO NOT attend the meeting/event unless you have been given specific permission to do so by the organiser.
Sign above
25-10-2020
The information you entered above will be used only for the purposes of processing and contacting you with regard to your request to participate in 1st The Hague Scout Group meetings and events. We will not use this information for any other purpose. See our privacy policy for more details.