Statement of Symptoms and Quarantine
Statement of Symptoms and Quarantine

Statement of Symptoms and Quarantine.
Pursuant to the Governor of New Hampshire’s Emergency Order 27, all registered guests must
attest that they are exhibiting no symptoms of COVID-19. Additionally, registered guests
checking in must either provide a Driver’s license or valid ID proving residency from the states of New England. For guests travelling to us from any state not within New England they must attest that they have quarantined at home for 14 days, leaving their home only when necessary and while out wearing masks and maintaining social distance.
Symptoms Statement (Required by all guests.)

By signing this statement I, ___________________ (name) attest that no one in my party is
currently exhibiting any symptoms of COVID-19 such as:
1. Fever in the last 48 hours
2. Respiratory symptoms such as sore throat, cough, or shortness of breath
3. Flu-like symptoms such as muscle aches, chills, and severe fatigue
4. Changes in a person’s sense of taste or smell

Name: ________________________________

Signed: ________________________________ Date: ______________

Quarantine Statement (Required for out -of -state guests not residing in New England)
By signing this statement I, ___________________ (name) attest that myself and all of the
individuals staying with me in my rented room have been quarantined** at home for the past
14 days.
**The definition of quarantine in this instance means that the person or people registering to stay at this
lodging facility have remained isolated at home for the past 14 days, going into the community only for
necessities. In addition, when outside of the home, I/we have maintained social distancing and worn a
face covering when less than six feet from another person.

Name: ________________________________

Signed: ________________________________ Date: ______________