Attendance & Health Acknowledgment

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Friends, please fill out our combined form completely so that we can anticipate who is attending and adequately prepare our spaces. Thank you for your support and patience in this trying time.

Please fill out this form every week you will be present in the building. Let Pastor Brian know about changes between filling out the form and your attendance.

ATTENDANCE

Your answers will help us quickly sort our lists and check you in. Please check Sunday morning whether you are a helper or a participant.

Please check all that you will attend in the coming week: *

Sunday Morning

Cleaners (Sundays)

Small Groups

Work Groups & Committees

Other Church Work

Required

Which days will you be in the building? *

Check all that apply.

Last Name *

First Name *

Phone *

I have a mask and will bring it? *

Yes

No, I need one.

HEALTH ACKNOWLEDGMENT FORM

Please respond to the following questions, so we may keep you and other congregants gathering with you safe and healthy. These questions are to screen for persons who could transmit the virus causing COVID-19. The information will remain confidential and reviewed only by your local clergy. The District Superintendent, Bishop/Cabinet, and Department of Health will review only if necessary.
I acknowledge:
1. I have not had 2 or more of the following symptoms of COVID-19 in the past 14 days:
-Fever
-Shortness of breath or difficulty breathing Chills
-Persistent cough
-Flu-like symptoms
-Diarrhea or intestinal upset
-Fatigue
-Sore throat
-Headache
-Muscle pain
-Recent loss of taste or smell
2. I have not been in contact with anyone experiencing symptoms of COVID-19 (identified above) in the past 14 days.
3. I have not tested positive for COVID-19, nor am I awaiting test results, nor have I tested positive and have not subsequently had complete resolution of COVID19 symptoms.
4. I will immediately notify my pastor if after attending In-Person Worship I develop 2 or more symptoms of COVID-19, will avoid contact with others, and will seek medical attention.

I can answer ‘YES’ to all of the above questions. *

Yes

If you cannot answer ‘YES’ to all of the above, we ask you to wait before attending any in-person gatherings at church until you can answer affirmatively.

Name of person filling out the form.

PRAYER SUPPORT

Please share your prayer requests and coordinate a time to talk to one of our ministers.

Prayer Requests

Would you like a follow-up call?

Yes

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