Self -Certification Internatio nal Form SAR S-CoV -2 / Covid -19
a) NAME and SURNAME:
DATE of BIRTH:
NATIONALITY:
ID / PASSPORT NUMBER:
E- MAIL:
MOBILE PHONE:
b) NAME and SURNAME:
DATE of BIRTH:
NATIONALITY:
ID / PASSPORT NUMBER:
E- MAIL:
MOBILE PHONE:
exercisin g parental responsibility for the minor (hereinafter referred to as the “Signatory” ):
NAME and SURNAME:
DATE of BIRTH:
NATIONALITY:
ID / PASSPORT NUMBER:
E- MAIL:
MOBILE PHONE:
(Internazional Licence):
EVENT:
(hereinafter referred to as the “ Participant ”)
AWARE o f the cri minal penalties provided for in the event of false declarations and the creation o r use of
false deeds
DECLARES AND CERTIFIES UNDER HIS/HER OWN RESPONABILITY the following:
1. The Signatory has acknowledged the content of the GUIDELINES FOR T HE CONTR AS T OF TH E DIFFUSION OF
COVID -19 IN FEDERAL SPORT ING EVENTS FMI , which current version is available at
https://w ww.feder mo to.it/p ubblicate -le-linee -guida -delle -discipline -fmi -per -il-contrasto -della -diffusione –
del -covid -19/ ;
2. The Signatory accepts and agrees to be abide by the GUIDELINES FOR THE CONTRAST OF THE DIFFUSION OF
COVID -19 IN FEDERAL SPORTING EVENTS FMI , i ncluding the rule s, measures and recommendations
contained therein, during and in connection to the Event ;
3. The Signatory has taken note of the contents of the Ordinance of the Minister of Health of 12 August and of
the Regional Ordinances which contain hea lth prov isions fo r those entering Italy ;
4. The Signatory hereby declares that The Participant :
A. Not currently being positive for SARS -CoV -2 / COVID -19 , not been previously diagnosed with SARS –
CoV -2 / COVID -19 and being investigated as per the protocol in the case of COVID + asc ertained and
cured and not being subjected to the quarantine measure ;
B. Have’nt you experienced any symptoms (e.g. fever, chest pain with or without dyspnea (shortness of
breath), dry cough, gastroenteritis / diarrhea, asthenia (u nusua l t iredness), anorexia (decreas ed
appetite), loss of taste or smell and/or others according to the updated local official regulations /
indications about Public Health related to Covid -19 disease that may be compatible with SARS -CoV -2
/ COVID -19 in th e la st 1 4 days ;
C. Have’nt you been in contact with any person diagnosed with SARS -CoV -2 / COVID -19 in the last 14
days;
D. Have carried out what is required according to the Ordinance of the Minister of Health 28/3 and 12/8,
the Regional Ordinances and the curr ent proc edures and health p rovisions for those entering to Italy
depending on the country of origin .
a) For acceptance upon check -in at the Event
Date:
Signature:
Name:
b) For acceptance upon check -in at the Event
Date:
Signature:
Name:
