SYMBIOSIS OPEN EDUCATION SOCIETY

&
SYMBIOSIS FOUNDATION
Self-Declaration form for student
Name of the Student:

Gender: Male Female

Age:

Residential Address:

Name of the Institution:

Stream:

Q1) Are you experiencing any one of the following?

a) Cough

b) Fever

c) Difficulty in breathing

d) Any major illness

f) None of the Above

Q2) Are you suffering from Diabetes / High BP / any respiratory disease / heart disease?  Please
mention.

Q3) Were you quarantined during lockdown period by Government authority? If yes, mention
reason and period.

Q4) If you were quarantined during lockdown period, whether you have received fitness certificate?
If yes, please attach with this document.
Q5) Whether you have interacted or lived with someone who has tested positive for Covid-19?

Q 6) Has any of your family members got treated for COVID 19? Yes / No if yes-mention relation
relation

Q 7) Was any one from your society tested positive for COVID 19? Yes / No --------------------

I hereby declare that information given above is true and that I will use cleaned and regularly
washed face mask, will use own sanitizer and maintain social distancing.

Date: Signature