Harris Institute Quarantine Plan

After submission, you will receive a copy of your completed form to the email address provided below. Please ALWAYS keep a digital copy of this form on your phone AND you will be required to show a PRINTED copy to be allowed entry in Canada so print it BEFORE going to the airport.

First Name *

Last Name *

Email: *

Date of birth: *

Phone number: *

Country of origin: *

Passport number: *

Home Address: *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Arrival Information

Arrival Date: *

Arrival from: *

Arrival by (airline name and flight number): *

Port of entry into Canada: *

Quarantine Plan

Quarantine location: *

CASA Toronto
Other

Please provide the address of your quarantine location: *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

I confirm that the following are provided by the quarantine site: *

Transportation to quarantine location
3 meals/day, delivered to my room AND/OR a kitchen
Access to needed toiletries, linen, cleaning supplies etc.

Address in Canada after self-isolation *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Medical Insurance Information

I confirm that: I am entering Canada with medical insurance that provides coverage for COVID-19 during the mandatory quarantine upon entry period. *

Name of my medical insurance company: *

Policy number of my medical insurance: *

Commitment to this plan

By signing this form, I certify that I understand the importance of the quarantine procedure upon arrival in Canada, and will follow all criteria provided in this document, as well as all requirements provided by the Government of Canada, for a full 14 days.

Candidate eSignature *

(type your name)

Date of eSignature: *