Covid-19 Self Declaration Form

Covid-19 Self-Declaration Form_New Students

Covid-19 Self-Declaration Form_New Students

To help prevent the spread of COVID-19 in the school, every student must complete and sign a COVID-19 Self-Declaration Form before starting their course in Galway. On review of the form, management may contact you to ask you not to start school immediately, and in this case, will discuss a suitable alternative date for your start.

Do you have an EU Digital Covid Certificate? *
Do you have a negative result from an RT-PCR test taken no more than 72 hours before your arrival in Ireland? *
Do you have symptoms of Covid-19 now or have you had symptoms in the past 14 days? (Symptoms of Covid-19 are: cough, fever, high temperature, sore throat, runny nose, breathlessness or flu like symptoms) *
Have you been diagnosed with a confirmed or suspected COVID-19 infection in the last 14 days? *
Are you a close contact of a person who is a confirmed case of COVID-19 in the past 14 days? *
Have you been advised by a doctor to self-isolate at this time? *


(Please Read Carefully)
I have completed the COVID-19 Passenger Locator Form before arrival. *
I have read and understood my obligations after arriving in Ireland. I declare to follow the Irish government regulations. *
I am aware of current restrictions in place in Ireland. *
I have read and understood Atlantic Language School's Safety Protocols. *

Emergency Contact Details

Does your emergency contact speak English? *

Confirmation and Data Protection

I confirm that the above information is correct. I agree that my data may be used to contact me to verify the provided information and that it may be used for the purposes of contact tracing in relation to confirmed or suspected cases of Covid-19, or in case of an emergency. If this information changes while you are a student at our school, please inform us asap

I consent to the use of my details for the purpose of processing this form.
Please tick this box to confirm you have completed this form accurately.