Customer COVID-19 Declaration – Lithgow Tourist & Van Park

As a Customer of Lithgow Tourist and Van Park, I agree to the customer rules and conditions, and I agree: *

1. I am not displaying flu-like symptoms and I have not tested positive to COVID-19 in the last 21 days. I will inform management if I develop any COVID-19 symptoms.
2. I understand that I cannot self-isolate at the Caravan Park because it does not have appropriate facilities. If I develop symptoms, I agree to checkout and seek medical help.
3. I will adopt good hand hygiene practices, abide by the 4 square metre social distancing rule and respect all NSW Health rules and recommendations.
4. I agree to a random temperature check on arrival if asked.

Please provide any other relevant information (recent COVID test, vaccination record):

Name *

First

Last

Mobile Number *

Email *

Address *

Suburb/Town *

Postcode *

Date *

I confirm that the information provided above is correct and can be provided to NSW Health if requested (When you click SUBMIT a copy is sent to our Office). (Form revision 1.4 dated 19 September 2022)

Name