As the Covid situation changes quickly, please refer to our latest update (found under 'News') regarding social leave or ring Reception prior to completing this form. Note. All fields must be completed.First Name*Last Name*Location in Maroba where the resident reside*HoneysuckleNobby’sThe HillWaratahBlue gumJacarandaPickup Date* Date Format: DD slash MM slash YYYY Pick up Time* : H M AMPM Return Date* Date Format: DD slash MM slash YYYY Return Time* : H M AMPM Reason for Excursion*Medical AppointmentSocialName of person accompanying the resident*If Medical Appointment, Name of Business and Address*If Social Appointment- Street Address*Number of People Attending*For Social Outings - Where do the people attending live (Suburbs)?*How do you intend to keep your loved one safe?* Avoid Large Gatherings Cough and Sneeze Etiquette Hand Hygiene Social Distancing Have no contact with individuals from outbreak areas OtherPlease specify Other*In the past 14 days has any person in attendanceReturned from or had contact with anyone who has been overseas or interstate;*YesNoPlease specify where you have travelled?*Been in contact with someone confirmed to have COVID-19*YesNoHave a fever (37.5°C or higher) or any symptoms consistent with COVID-19 infection, even if mild. Symptoms of COVID-19 include fever, headache, fatigue, runny nose, sore throat, shortness of breath, loss of taste, loss of smell, loss of appetite muscle pain, joint pain, diarrhea or nausea/vomiting.*YesNoName of Person Completing the Form*Contact Number*In accordance with current Public Health Order; residents can attend small family gatherings, preferably outdoors and wearing a mask, where physical distancing is not assured with minimal contact with other people in the community.CAPTCHACommentsThis field is for validation purposes and should be left unchanged.