CUMC Health Acknowledgement Form
For tracking purposes, it is imperative that this form be completed and submitted by noon on Wednesday for Sunday Worship, or 4 days prior to attending any other in-person service at Community United Methodist Church. A new form must be completed each week for the next service that you plan to attend. The information you provide will be sent directly to the Senior Pastor. You will be notified of your approval status at least 24 hours prior to the service. The number of attendees is limited and will be accepted on a first come, first served basis. If you cannot answer ‘I agree’ to all 4 questions, we ask you to wait before attending any in-person gatherings at church until you can answer affirmatively.

Your responses will be verified by an usher/greeter when you arrive at the church. Take your temperature before leaving home, bring a mask, and keep 6' of distance between you and other church members (outside of your family). Designated restrooms will be open, but we request that they be used only if necessary and with compliance to posted guidelines.

                             **PLEASE READ CUMC's HEALTHY CHURCH PLAN (at cumcvb.org)!**
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Select the Service or Event you plan to attend. *
Date of service you plan to attend (this week only) *
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Your FULL name (first and last) *
List the first names of all family or household members who will be attending with you. Your responses to the questions on this form should apply to every attendee.
Total # attendees from your household *
Preferred contact information (phone # and/or email). You will receive confirmation of attendance via this method, so please be sure it is typed correctly. *
1. I confirm that I (we) have NOT have 2 or more of the following symptoms of COVID-19 in the past 14 days: *Fever *Shortness of breath/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 confirm that I (we) have not been in contact with anyone experiencing symptoms of COVID-19 (identified above) in the past 14 days. *
3. I confirm that I (we) 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. *
Thank you, you will receive confirmation soon! You may write any other additional comments here.  PLEASE NOTE HERE IF YOU NEED TO USE THE WHEELCHAIR RAMP ENTRANCE SO WE CAN SAVE YOU A PARKING SPACE.
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