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

    Uploaded by

    Gerome Bautista VInluan
    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.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

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

    Uploaded by

    Gerome Bautista VInluan
    31 views1 page
    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.

    Original Title

    LIS Revised.docx

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    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.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    31 views1 page

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

    Uploaded by

    Gerome Bautista VInluan
    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.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 1

    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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