Annex A

(revised)

Registration Form
(Locally Stranded Individual)

*First Name: *Middle Name: *Last Name: Suffix:

*Gender: *Contact Number: *Age: *Occupation: *Type of LSI Worler,

Male Female Student, Tourist, Individual
Stranded in Various Localities
while in transit, Other
Others

*Destination: Region, Province, City/Mun, Brgy *Origin LGU: Region, Province, City/Mun, Brgy

*Date of Travel to **Vehicle: **Driver’s Name and *Date of Travel to

Residence: Private Government Contact Number: Residence:
(DD/MM/YY)

**Emergency Contact Person and Contact *Preferred Main Mode of **Other Assistance
Number: Transportation: Needed by LSI:
Land, Sea, Air Provision of Transportation
Service, Food Assistance

Medical Clearance Issued by the
City/Municipal Health Office:
Yes, Date of Issuance: __________________
No, Reason: __________________________
A Medical Clearance Certification issued by the City/Municipal Health
Office based on the following conditions:
 That the LSI is neither a contact, suspect or probable or confirmed
COVID-19 case; and
 That the LSI completed a 14-day quarantine based on the quarantine
standards set by the DOH; or
 That LSI confirmed as a COVID-19 case was tested negative through
RT-PCR twice.

Note:
* - Mandatory Field
** - If available