Health  and Wellness Screening
To comply with MA guidelines, each Sunday, each attendee complete a new wellness screening PRIOR to service.

Every individual requires their own separate copy of this form.

Printed copies will be available at the Church, if needed. All responses and individual check information will be maintained on file.
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Attendees Name *
Email *
Today, or in the past 24 hours, has the participant or any household members had any of the following symptoms: *
Required
In the past 14 days, has the participant had close contact with any person known or suspected to be infected with the novel coronavirus? *
Required
Do you have any household members awaiting novel coronavirus (COVID-19) test results or asked to quarantine? *
Required
In the past 14 days, has the participant or any household member traveled to a restricted area, according to MA state COVID regulations? *
Required
I am reporting all responses of the attendee accurately. I understand that if any of the above answers are yes, my child will not be allowed to participate and therefore must stay/return home with their parent/guardian or caregiver. *
Required
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