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Registration Form (Locally Stranded Individual) : Annex A (Revised)

This document is a registration form for locally stranded individuals (LSIs) seeking to return to their home regions. It collects contact information, travel details, emergency contacts, transportation preferences, and medical clearance status to facilitate their safe return. Key information includes name, gender, contact details, age, occupation, origin and destination locations, travel dates and vehicles, emergency contacts, preferred travel mode, and confirmation of medical clearance.

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Gerome Bautista VInluan
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71 views1 page

Registration Form (Locally Stranded Individual) : Annex A (Revised)

This document is a registration form for locally stranded individuals (LSIs) seeking to return to their home regions. It collects contact information, travel details, emergency contacts, transportation preferences, and medical clearance status to facilitate their safe return. Key information includes name, gender, contact details, age, occupation, origin and destination locations, travel dates and vehicles, emergency contacts, preferred travel mode, and confirmation of medical clearance.

Uploaded by

Gerome Bautista VInluan
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Annex A

(revised)

Registration Form
(Locally Stranded Individual)

*First Name: *Middle Name: *Last Name: Suffix:

*Gender: *Contact Number: *Age: *Occupation: *Type of LSI Worler,


Male Female Student, Tourist, Individual
Stranded in Various Localities
while in transit, Other
Others

*Destination: Region, Province, City/Mun, Brgy *Origin LGU: Region, Province, City/Mun, Brgy

*Date of Travel to **Vehicle: **Driver’s Name and *Date of Travel to


Residence: Private Government Contact Number: Residence:
(DD/MM/YY)

**Emergency Contact Person and Contact *Preferred Main Mode of **Other Assistance
Number: Transportation: Needed by LSI:
Land, Sea, Air Provision of Transportation
Service, Food Assistance

Medical Clearance Issued by the A Medical Clearance Certification issued by the City/Municipal Health
Office based on the following conditions:
City/Municipal Health Office:  That the LSI is neither a contact, suspect or probable or confirmed
Yes, Date of Issuance: __________________ COVID-19 case; and
 That the LSI completed a 14-day quarantine based on the quarantine
standards set by the DOH; or
No, Reason: __________________________  That LSI confirmed as a COVID-19 case was tested negative through
RT-PCR twice.

Note:
* - Mandatory Field
** - If available

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