Self Declaration Form

AONB and Geopark Volunteer Self Declaration

DECLARES UNDER ITS OWN LIABILITY, PURSUANT TO THE REGULATION IN FORCE, AS FOLLOWS:
Name*
Title Forename Surname
hereby certify that I have not within the last 14 days;
1. Being affected by COVID-19 (ie Tested positive or am presumptively positive with the Coronavirus or been identified as a potential carrier.)
2. Experienced any symptoms commonly associated with the Coronavirus. (e.g. suffering from fever with a temperature above 37,5° C; have a persistent cough, difficulty breathing, cold, sore throat, headache, severe weakness (tiredness), decrease or loss of smell/taste, diarrhoea).
3. Having had close contacts with person affected by COVID-19, for two days before the occurrence of symptoms and up to 14 days after the occurrence of the symptoms.
4. Been in any location designated as a risk by the Government or Public Health Service Northern Ireland.
I also undertake to inform the Newry Mourne and Down District Council through the AONB and Geopark Team and Local Health Authority of any possible occurrence of above mentioned symptoms arising within eight days of taking part in this volunteer activity.

To allow the traceability of the undersigned in the following 14 days from carrying out this volunteer activity I have provided my residential address/telephone/mobile number/e-mail address.
Address*
Address City ZIP / Postal Code Country
Tel Number:
Daytime*
Evening
Mobile
Email Address*
Date of Birth*
DD slash MM slash YYYY
Volunteers Health Declaration
Volunteers Health Declaration – “I understand that being a volunteer may be physically demanding. I consider myself fit to undertake the tasks I have expressed an interest in and agree to inform the AONB and Geopark Team of any changes to my health.”
Signed*

Please enter your name here.
Date*
DD slash MM slash YYYY

Please enter today's date.
Privacy Policy
I acknowledge and accept that this declaration will be considered as my consent to record and store this declaration for the purpose of ensuring the safety of all persons that may encounter me during my volunteering time. It will be retained in electrical copy format at the point of collection and will only be accessed by authorised employees. We will only retain this information for as long as it remains relevant and for a maximum of six months. NMDDC privacy statement available on request.
Consent
I permit Newry Mourne and Down District Council to take photos of me and for these photos to be used to promote the AONB and Geopark in publications, press articles and websites for non-profit making purposes.
Signed*

Please enter your name here.
Date*
DD slash MM slash YYYY

Please enter today's date.
The Data Protection Act 2018 sets rules for processing personal information. The data we have asked for is collected for administrative and insurance purposes, and to allow us to contact you with matters which may interest you. This information is for the sole use as described above.
CAPTCHA

To help prevent the spread of COVID-19 and reduce the potential risk of exposure, we are conducting a simple screening declaration form (“Declaration”). Your participation is important to help us take precautionary measures to protect you and everyone associated with our projects. The information on this form is confidential.