COVID-19 Certification Questionnaire
Elejmal Temple No. 185 and Elejmal Court No. 171 are mandated and required by the CDC, New York State Law, and The State Health Department to adhere to COVID-19 regulations and practices.

Completion of this form certifies that you are aware of the regulations and agree to them.

At all times, you are required to:
1. To wear a mask (except when eating)
2. Adhere to the social distancing policy

We will only use the information you provide if we need to contact you.  

1. View Our Face Covering Policy - https://bit.ly/3t7AX1g

2. View Our Privacy Policy - https://bit.ly/38D2cYa

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Email *
First Name *
Last Name *
Mobile Telephone Number *
Please enter your mobile telephone number. Please only enter the numbers.
Please Select One Option *
Required
I have checked my temperature and it is less than 100.4⁰ F (38⁰ C). *
Required
Have you or anyone in your household tested positive for COVID-19 in the past 30 days? *
Required
Have you experienced any symptoms of COVID-19 (e.g., fever, cough, unexplained shortness of breath, new loss of taste or smell) in the last 48 hours? *
No
Yes
Fever
Cough
Difficulty Breathing
Loss Of Taste Or Smell
Date of event you attended? *
Please use this format: mm/dd/yyyy or click on the calendar icon to select date.
MM
/
DD
/
YYYY
A copy of your responses will be emailed to the address you provided.
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