Health Declaration Form - COVID-19
Required to be submitted for every passenger at least 24 hours prior to the scheduled flight departure time.
I [enter name below] hereby certify, represent and warrant as follows:
Within the twenty-one (21) days immediately preceding the date of the Health Declaration Form ("Declaration"), I have NOT:
The following are all locations I have visited over the previous twenty-one (21) days and the modes of transportation used for such visits:
I agree to notify Dumont (by email to email@example.com) of any change in status, including diagnosis with Coronavirus and/or any quarantine, within thirty (30) days either before or following a Dumont flight.
I will wear a mask (of the specifications recommended by Dumont or the flight operator) at all times while a passenger on any flight with, or arranged by, Dumont, and will take all reasonable prophylactic steps that may be recommended by Dumont, the flight operator and/or any relevant public authority.
I acknowledge and understand that certain charter operators are requiring passengers to consent to having their temperature taken prior to, during, and after flights. While I understand that Dumont is not requiring such testing, certain operators with which Dumont may arrange flights may require such testing, and I hereby consent to such testing by an agent of the flight operator and hereby waive and release any claims I may have against Dumont related in any way to such testing, the results of such testing, or any actions taken as a result of such testing. Dumont reserves the right to implement and require such testing if mandated or advised by an applicable government or public health agency.
I acknowledge and accept that that this Declaration shall be governed by the laws of the State of Delaware. I irrevocably agree that the courts of the State of Delaware 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, and further agree any and all such disputes shall be venued exclusively in the courts of Delaware and hereby waive any objection or defense based on improper venue or inconvenient forum. Nothing contained herein shall limit the right of Dumont to institute any emergent 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 Dumont 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.
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 U.S. Presidential proclamation, upon Dumont 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 hereby affirm that all the above statements apply equally to the following minors under the age of 18 traveling with me or with my consent on any Dumont flight and who are in my custody or care, if any (Please list below Name/Surname, Passport No and Country issuing passport for each minor traveling)
If any above statement in this Declaration is not wholly true, complete and accurate, please provide a full explanation here:
In submitting this form, I attest and represent that I am an individual over the age of 18 of sound mind and I am knowingly, voluntarily and freely agreeing to the terms of this binding Declaration, and that the statements and information provided above are true, complete and accurate.
Please provide information below as follows;