Individual Health Acknowledgement Form

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Please complete before you attend a small group gathering at Shady Grove UMC, Mechanicsville. Information may be shared with group leaders, clergy, the District Superintendent or the Bishop if necessary.

Name of Event Attending (Youth group, Tuesday morning Bible Study, Bell Rehersal, Witness meeting, etc.)

Date of Event (Should be today's date) *

YYYY

Time of Event *

Time

Participant's Name *

Telephone Number *

Email Address

Please place a checkmark in each box acknowledging the following: *

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.

I have not been in contact with anyone experiencing symptoms of COVID-19 (identified above) within the past 14 days.

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 COVID-19 symptoms.

I will immediately notify my pastor if after attending an in-person gathering I develop 2 or more symptoms of COVID-19, will avoid contact with others, and will seek medical attention.

Required

If you cannot answer yes to all of the above, we ask that you wait before attending any in-person gathering at church until you can answer affirmatively. *

I can answer "Yes" to all of the above questions.

No, I need to exit this form and agree not to enter SGUMC until I can answer affirmatively.

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