Student Affidavits for Regulatory Bodies

Hello! This community has been so helpful. This is the first time I've had to post a question because I hadn't found a post that already addressed it.

We provide continuing education to insurance adjusters in mutliple jurisdictions. The regulatory bodies all have different requirements regarding student affidavits and proctor affidavits. Some are VERY picky and the wording, etc. has to be exact. I am trying to figure out the best way to recreate them in Presenter or Quizmaker. It seems like it should be able to be done using a quiz or survey but I haven't been able to figure out the best way. I've attached one from one of the pickier states so you can see exactly what has to be provided. I can do it on multiple slides, I just don't want it to have to be one slide per fill-in-the blank when it comes to things like name and date, etc.

Please check out the attached... any advice on the best way to re-create this would be greatly appreciated!!