Sri Bhaktha Anjaneya Temple - Sri Bhaktha Anjaneya

COVID-19 SELF DECLARATION

Have you or any of your immediate family or persons sharing the same residence as you, been diagnosed with COVID-19 in the last 10 days? Yes No

Have you had close immediate contact with or cared for someone diagnosed with COVID-19 within the last 10 days?
Yes No

Are you experiencing any of the following symptoms: fever, loss of taste and smell, cough, sore throat, difficulty breathing, redness of eyes, or similar COVID-19 related symptoms? Yes No

Any of your guests who travelled from abroad in last 10 days for this pooja?
Yes No

Declaration

By clicking the "I agree" button below, I hereby declare that:
The information provided is to the best of my knowledge accurate, truthful & correct in all respects, and I have not omitted to disclose any information.
I shall immediately notify a security representative at the property of any change relating to the information provided which may occur during the course of my visit to the property.
I consent to my personal information being provided to the requisite regulatory authority for the purposes of contact tracing relating to the prevention of the spread of the Covid-19 virus.
Given the nature of the Covid-19 virus, I know & understand the risks of exposure to the virus that may occur at the property & agree that I cannot hold Sri Baktha Anjaneya Temple (SBAT), its subsidiaries, associated companies, directors, managers, employers and contractors ("the indemnified parties") liable for the transmission of or any outbreak of the virus at the property. I hereby indemnify and waive any right that I may have to institute any claim against the indemnified parties in relation to the Covid-19 virus and/or the contraction thereof.

First Name:

Last Name:

Phone Number:

Mobile Phone Number:

Pooja Name:

Your Email:

Requested Priest:

Requested Program Date:

Preferred location:

Preferred Language:

Enter number of Adult(s):

Enter number of children (under 5 years):

Message:

Home Address

Address line 1:

City:

State:

Zipcode:

Pooja Address (Required)

Same as above address: Yes No