Covid-19 Questionnaire for attending services at BFMC Building on Sunday, January 23, 2022.

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Hello Church Family! We look forward to being together this Sunday. Please take a minute to complete this form ONLY if you or someone in your household is planning to attend the service in the church building this Sunday, February 27th. Thank you for your cooperation and support as we work together to hold services in the church in a safe and responsible manner.

NOTE: In compliance with the Simcoe Muskoka Health Unit, face coverings are required inside the church building. If you are immuno-compromised or have an existing health condition, we strongly recommend that you remain at home and join the service online.

# of people attending in your household: *

Names of those attending in your household: *

Main contact information: (please include both the email & phone # of your household): *

Please check the boxes below. IMPORTANT: If anyone in your household cannot answer YES to all of the following statements, we ask that your family please remain at home and join the service online: *

I/We HAVE NOT been directed to self-isolate in the last 14 days by a Health Care Provider.

NEW (as of Nov 23/21): If a person (including children) in your household (who is not fully vaccinated) has been in contact with someone who has been told to self-isolate, they too must self-isolate for 10 days, even if they don’t have symptoms. By CHECKING THIS BOX you are confirming that this DOES NOT APPLY to anyone attending church.

I/We DO NOT have any of the following symptoms: fever (>37.8°C/100°F), chills, congestion/runny nose, pink eye, headache that's unusual or long lasting, digestive issues (nausea, vomiting, diarrhea, stomach pain), unexplained fatigue, cough, shortness of breath, sore throat, difficulty swallowing, decrease or loss of taste or smell.

I/We HAVE NOT traveled internationally within the last 14 days.

I/We HAVE NOT had close contact (including living with or prolonged contact within 2 meters without protective equipment) with either of the following: (1) a confirmed COVID-19 case, or (2) a person who has returned to the country within the past 14 days, or (3) a person with COVID-19 symptoms in the past 10 days.

Required

I/We (all those in your household over the age of 2) agree to wear a mask at all times inside the church building. I/we acknowledge the contagious nature of COVID-19, especially if I/we are immunocompromised or have an existing health condition or disease, and voluntarily assume the risk that I/we may be exposed to or infected by COVID-19 by attending Barrie Free Methodist Church, and that such exposure or infection may result in personal illness, injury, permanent disability, or death. I/we understand that we may be visible in the congregation from time to time during the live stream of the service. I/we agree to abide by all rules and recommendations posted on signs on the premises and otherwise communicated in writing or verbally. I/we hereby release, covenant not to sue, discharge, and hold harmless Barrie Free Methodist Church. I/we understand and agree that this release includes any and all liabilities, claims, actions, damages, costs or expenses of any kind based on the actions, omissions, or negligence of Barrie Free Methodist Church, its officers, employees, volunteers, and representatives. *

I/We agree

Required

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