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OUR COVID-19 SAFETY COMMITMENTS
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Self Declaration Form
Covid-19 Hotel Stays
Please fill out one form per person prior to arrival to the hotel.
In light of the global risks associated with COVID-19, no Company can guarantee a risk-free environment and protection against the spread of COVID-19 is a joint responsibility between our guests and Hotel team. Preventative measures are in place throughout the hotel and these protocols and precautions must be complied with by all.
Therefore, in the interests of safety of guests, Hotel team, visitors, families and the wider community, we ask that you complete the following self-declaration form prior to your arrival at the Hotel. Your co-operation and support are appreciated in helping protect everyone in our hotel.
All information obtained through this form will be stored in line with the Data Protection Policy.
Name
*
First
Last
Address
*
Street Address
Address Line 2
City
County / State / Region
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Email
*
Have you any of the following symptoms now or in the past 14 days?
Cough
Fever
High Temperature
Sore Throat
Runny nose
Breathlessness
Flu like symptoms
Lack of sense of smell
Lack of Sense of taste
Have you been diagnosed with confirmed or suspected COVID-19 infection in the last 14 days?
*
Yes
No
Do you live in the same household/or have you been in close contact with someone who has symptoms of COVID-19 and/or who has been in isolation within the last 14 days?
*
Yes
No
Are you a visitor to the island of Ireland and or returning from another country (including Northern Ireland) within the last 14 days?
*
Yes
No
If ‘YES’, please state the country?
If you have left the Republic of Ireland for any period of time, you are required to self-isolate for a period of 14 days prior to returning back into the country, do you understand this requirement?
*
Yes
No
I confirm that I have responded to the questions above truthfully based on my current condition and I commit to advising the Hotel if this situation changes.
*
Confirm
Date
*
DD
MM
YYYY
We recommend you download the Irish Government Covid19 Tracker App.
