Health Declaration Form - COVID-19
Required to be submitted for every passenger on the reservation to email@example.com
at least 24 hours prior to the scheduled flight departure time.
hereby certify, represent and warrant as follows:
Within the twenty one (21) days immediately preceding the Date of this Health Declaration Form (“Declaration”),
I HAVE NOT:
a. tested positive or presumptively positive with the Coronavirus or been identiﬁed as a potential carrier
of the COVID-19 virus or similar communicable illness (“Coronavirus”);
b. experienced any symptoms commonly associated with the Coronavirus;
c. been in any location positively designated as hazardous and/or potentially infected with the Coronavirus
by a recognized health or regulatory authority, such as a country for which the Center for Disease Control
and Prevention (“CDC”) issued a Level 3 Travel Advisory for Coronavirus;
d. been in direct contact with or the immediate vicinity of any person I knew and/or now know to be
carrying the Coronavirus or has been identiﬁed as a potential carrier of the Coronavirus.
I CAN account for all locations visited over the previous twenty one (21) days and shall provide an exhaustive list of all locations visited
and modes of transportation used below (please attach an additional page as needed):
I AGREE to notify XO (by email to firstname.lastname@example.org) of any change in status, including diagnosis
with Coronavirus and/or quarantine, within thirty (30) days either before or following an XO flight.
I WILL, if asked, wear a mask (of the speciﬁcations recommended by the flight operator) at all times while
a passenger on any flight arranged by XO, and will take all reasonable prophylactic steps that may be recommended by XO, flight
operator and/or any relevant public authority.
I WILL consent to having my temperature taken by any representative or agent of the flight operator prior, during, and after any flight
arranged by XO, and will provide any follow up information reasonably requested by XO.
I ACKNOWLEDGE and ACCEPT that this Declaration shall be governed by the laws of Florida. I irrevocably agree that the competent Courts
of Florida shall have jurisdiction to hear and determine any suit, action or proceeding, and to settle any dispute which may arise out of,
under, or in connection with this Declaration and for such purposes hereby irrevocably submit to the jurisdiction of such Courts. Nothing
contained herein shall limit the right of XO to take proceedings in any other Court of competent jurisdiction nor shall the taking of
proceedings in one or more jurisdiction preclude the taking of proceedings in any other jurisdiction whether concurrently or not.
I ACKNOWLEDGE and ACCEPT that this Declaration will be considered as my consent to XO to disclose, share, record and store this
Declaration with any relevant authority or service provider for the purposes of ensuring the safety and security of any and all third parties
that may come in contact with me prior, during, and after any flight.
(insert full name)
If over the previous twenty one (21) days prior to the flight, I have visited any of the countries, states or regions that have a
CDC Level 3 Travel Health Notice or travel to which is restricted subject to US President’s proclamation, upon XO or flight
operator’s request, I AGREE to provide a written veriﬁcation executed by a licensed physician or a medical facility prior to
boarding a flight conﬁrming that (i) a CDC-approved Coronavirus test was administered on me and was negative or (ii) I do
not meet the CDC criteria for administering a Coronavirus test and do not exhibit any Coronavirus symptoms.
I AFFIRM that all the above statements apply equally to the following minors under the age of 18 travelling (either with me or
with my consent) on any XO flight and who are in my custody or care, if any (please attach an additional page as needed):
Name/Surname: ; Passport No: ;
Country issuing Passport:
If any above statement is not wholly true, please provide a full explanation here:
In signing below, I, an individual over the age of 18 of sound mind, knowingly, voluntarily, and freely agree to the terms of this
binding Declaration, and in doing so represent the truthfulness and veracity of the above answers.
(Passport or a Valid Government issued ID Number)
(Country/State/Department Issuing the Document)
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