Attestation Form - Church of the Immaculate Conception
In compliance with NYS Directives and Diocesan Guidelines we are required to collect this information for all liturgical celebrations - Mass, Funerals, Baptisms, Weddings - held within the Church.  We appreciate your cooperation.  Please note:  ONLY ONE FORM IS NEEDED FOR EACH HOUSEHOLD.
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Date of Attendance *
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Please select which type of liturgical celebration you are attending *
Last Name *
First Name *
Phone Number *
Email Address *
Total number of people that will be seated with you *
By checking the box below I attest to the following (1) no one I am signing up today has experienced any symptoms of Covid-19 in the past 10 days  (2) no one I am am signing up has tested positive for Covid-19 in the past 14 days and (3) no one I am signing up has been in direct contact with anyone who has tested positive or is suspected of being positive with Covid-19 in the past 10 days. *
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