SurveyMonkey Powered Online Survey

One submission per card carrying Member, including Junior Members 12 to <25 years old.

If your travel history changes or if there is an update to your circumstances, please fill out the Declaration Form again.

MINISTRY OF HEALTH STAY-HOME NOTICE (SHN): An SHN is a legal order for anyone with recent travel history to remain in their place of residence at all times for a 14-day period upon return.

QUARANTINE ORDER (QO): Any persons issued a QO must not leave their designated location for any reason.

For more information, visit www.moh.gov.sg.

Members must not come to The Club if:
• Unwell
• Living with someone serving SHN or QO

If a Member or persons living with Member has/have returned from travel within the past 14 days, the entire family must not come to The Club.

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* Membership No.
Please fill in your full membership number (e.g. A123400 / A123401 / A123402)

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* 1. Have you traveled in the past 14 days?

YES

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* If YES, please list all the countries you have visited over the past 14 days.

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* If YES, when did you last return to Singapore?

Please enter the date you last returned below.

Date

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* 2. Are you currently under close monitoring or surveillance by the Ministry of Health?

YES

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* 3. Have you had close contact or are you staying with a person currently on SHN?

YES

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* 4. Have you had close contact* with a person diagnosed with COVID-19 in the last 14 days?
*cared for, lived with or had direct contact with bodily fluids from a confirmed case

YES

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* 5. Have you been in close contact with anyone who has returned from overseas travel within the last 14 days (including anyone who has traveled but has not been issued an SHN or a QO)?

YES

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* By checking this box, you agree that The American Club may collect and use your personal data internally, as provided in this Travel and Health Declaration Form, for the purpose of enhancing Member safety during the COVID-19 outbreak. In accordance with the Personal Data Protection Act 2012 and The Club’s data protection policy, this data will not be shared or used for any other purposes.

I agree

Thank you for doing your part to protect The American Club community. Stay safe and socially responsible, and we will get through this together.

Question Title

* Membership No.Please fill in your full membership number (e.g. A123400 / A123401 / A123402)

Question Title

* 1. Have you traveled in the past 14 days?

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* If YES, please list all the countries you have visited over the past 14 days.

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* If YES, when did you last return to Singapore?

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* 2. Are you currently under close monitoring or surveillance by the Ministry of Health?

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* 3. Have you had close contact or are you staying with a person currently on SHN?

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* 4. Have you had close contact* with a person diagnosed with COVID-19 in the last 14 days? *cared for, lived with or had direct contact with bodily fluids from a confirmed case

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* 5. Have you been in close contact with anyone who has returned from overseas travel within the last 14 days (including anyone who has traveled but has not been issued an SHN or a QO)?

Question Title

* Membership No.
Please fill in your full membership number (e.g. A123400 / A123401 / A123402)

* 4. Have you had close contact* with a person diagnosed with COVID-19 in the last 14 days?
*cared for, lived with or had direct contact with bodily fluids from a confirmed case