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Cochran Avenue Baptist Church
Active Screening Membership Check-In for anyone above 18 years old. (New Registration)
This form is designed to identify possible symptoms of COVID-19 and/or other potentially contagious illnesses.
By submitting this form you are attesting that the following information is true and that to your knowledge you are not experiencing any signs of potentially contagious illness. Please note that you should not enter the Church Campus if you have any symptoms or feel ill.
This form has been adapted from the LA County Department of Public Health's COVID-19 Reopening Protocols. This form does not constitute medical advice and is for screening purposes only.
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* Indicates required question
Email
*
Your email
First Name
*
Your answer
Last Name
*
Your answer
Address:
Your answer
Do you currently have any symptoms of fever, cough, shortness of breath, chills, muscle pain, sore throat, or sudden loss of taste/smell?
*
Yes
No
In the last 14 days, have you or anyone in your household had contact with a confirmed or suspected case of COVID-19?
*
Yes
No
Do you have a fever above 100.4 degrees?
*
Yes
No
What service(s) will you be attending?
*
8:00 A.M.
10:00 A.M.
Required
How many people will be attending with you?
*
0
1
2
3
4
5
Name of child(ren) attending with you?
Your answer
I have read and understand the required COVID-19 guidelines to attend service(s).
*
Yes, I agree.
Required
A copy of your responses will be emailed to the address you provided.
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