Blue Heron Check In and Health Info Form

Name

Email Address

Phone

Home Address

Have you recently travelled overseas? (within the last 30 days) Have you recently travelled overseas? (within the last 30 days) Yes No

Within the last 14-days, have you experienced any of the below that you cannot attribute to another health condition? Within the last 14-days, have you experienced any of the below that you cannot attribute to another health condition? Coughing Shortness of breath Sore throat Muscle aches

Within the last 14 days, have you had close contact with someone who is currently sick with suspected or confirmed COVID-19? Within the last 14 days, have you had close contact with someone who is currently sick with suspected or confirmed COVID-19? Yes No

Have you had a temperature at or above 38°C/100.4°F or the sense of having a fever within the last 14-days? Have you had a temperature at or above 38°C/100.4°F or the sense of having a fever within the last 14-days? Yes No

Every person filling out this form and/or actually occupying accommodation or utilising other services shall be personally responsible for all charges in addition to the customers above names, notwithstanding that an account is sent in the first instance to that customer. It is a condition of occupancy that the person signing this document agrees to the Rules of the House. Note: The guest agrees that any damages done in the room or on the property is their responsibility and will be taken out of thier credit card if required. The proprietor/managers take no responsibility for loss or damage to goods or vehicles on the property. The guest agrees that any damage done in the room or on the property is their responsibility and will be taken out of their credit card if required. PLEASE NOTE: A CLEANING SURCHARGE WILL BE TAKEN FROM YOUR CREDIT CARD IF THERE IS ANY SIGN OF SMOKING IN ROOMS. IF THE ROOM HAS TO OUT OF ACTION FOR THE NIGHT AN ADDITIONAL ROOM RATE WILL APPLY. Accommodation is provided in accordance with the Traveller Accommodation Providers (Liability) Act 2001. My acknowledgement here under indicates that I have noted and accept the conditions contained herein. Every person filling out this form and/or actually occupying accommodation or utilising other services shall be personally responsible for all charges in addition to the customers above names, notwithstanding that an account is sent in the first instance to that customer. It is a condition of occupancy that the person signing this document agrees to the Rules of the House. Note: The guest agrees that any damages done in the room or on the property is their responsibility and will be taken out of thier credit card if required. The proprietor/managers take no responsibility for loss or damage to goods or vehicles on the property. The guest agrees that any damage done in the room or on the property is their responsibility and will be taken out of their credit card if required. PLEASE NOTE: A CLEANING SURCHARGE WILL BE TAKEN FROM YOUR CREDIT CARD IF THERE IS ANY SIGN OF SMOKING IN ROOMS. IF THE ROOM HAS TO OUT OF ACTION FOR THE NIGHT AN ADDITIONAL ROOM RATE WILL APPLY. Accommodation is provided in accordance with the Traveller Accommodation Providers (Liability) Act 2001. My acknowledgement here under indicates that I have noted and accept the conditions contained herein. I agree