Health Declaration Form for travelers entering Bonaire

To protect your health and the health of the general public of Bonaire, you are required by the public health department of Bonaire to complete this form. This form allows the public health officers to use your information to contact you when necessary in case of issues with regard to COVID-19. It is important to fill out this form completely and accurately. Your information is intended to be held in accordance with applicable laws and is used for public health purposes only. Thank you for your assistance to protect your health and the health of the general public of Bonaire.

One form should be completed by each person. Parents should complete this form for minors.

Please complete this form within 48 hours before your departure to Bonaire.

Please print this form after completion or save a digital copy on your phone or tablet. You may be asked to show this during your journey by a public health officer.

Seat row and letter: please note the row number and letter of your actual seat during the flight on your phone or a paper and save this for a minimum of 14 days after your trip.

Arrival date on Bonaire
Bonaire Resident
Departure date leaving Bonaire
Personal And Contact Information
Emergency Contact Information
Health Information

Do you have any of the following symptoms at this moment?
Please check the box if the answer is yes

Have you been in contact with a confirmed case of COVID-19 in the past 14 days?

In which countries, or on which island, have you stayed during the past 14 days? (Multiple answers are possible)

Do you have a medical or travel insurance, that covers COVID-19 related issues? (Note: Bonaire residents are insured via ZVK, and can answer this question with yes)

Did you do a COVID-19 PCR test within 72 hours prior to departure?

If you did a COVID-19 PCR test: what was the result?

Sign, Print and Send

I am a parent/guardian and completed this form on behalf of a minor: