Self -Certification Internatio nal Form SAR S-CoV -2 / Covid -19
NAME and SURNAME:
DATE of BIRTH:
NATIONALITY:
ID / PASSPORT NUMBER:
E- MAIL:
MOBILE PHONE:
(Internazional Licence ):
EVENT :
(hereinafter referred to as the “ Participant ” or also t he “ Signatory ”)
IN CONSIDERATION of being allowed to compete, officiate, observe, work, or participate in any way in the
EVENT( S) and/or being permitted to enter for any purpose any AREA of the CIRCUT(S) where the EVENT(S)
is/are held, and 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 THE CONTR AS T OF TH E DIFFUSION OF
COVID -19 IN FEDERAL SPORT ING EVENTS FMI , which current version is available at
https://www.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 , including 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 health prov isions fo r those entering Italy ;
4. The Participant hereby declares:
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
cure d 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 (unusua l tiredness), anorexia (decreas ed
appet ite), 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 the la st 14 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 current procedures and health p rovisions for tho se entering to Italy
depending on the country of origin .
For a cceptance upon check -in at the Event
Date:
Signature:
Name:
