Hyde Park Union Church Registration and Pre-Screening Form

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We are excited to have you with us for in-person worship! To help us prepare for Sunday, prevent the spread of COVID-19 and reduce the risk of exposure, we are conducting a simple screening questionnaire. Your participation will help us take precautionary measures to protect you and everyone that enters HPUC. We will also be using this form to contact trace our in-person worship, so please fill this out prior to arriving at the church. Thank you for your cooperation!

Household name *

How many people in your household are attending in-person worship? *

Phone number *

Today's date *

YYYY

Does anyone in your household have a fever or felt hot or feverish recently (14-21 days)? *

Yes

Has anyone in your household experienced shortness of breath or difficulties breathing? *

Yes

Does anyone in your household have a cough? *

Yes

Does anyone in your household have any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue? *

Yes

Has anyone in your house experienced recent loss of taste or smell? *

Yes

Has anyone in your house been in contact with someone that has COVID-19 recently (14-21 days)? *

Yes

Has anyone in your household traveled in the past 14 days to any regions with a COVID-19 travel advisory? *

Yes

If you have answered yes in response to the COVID-19 symptom questions, have you tested negative for COVID since your symptoms emerged?

Yes

Clear selection

Is your household fully vaccinated - children under 16 excluded? (Optional)

Yes

Clear selection

Finally, do you have any prayer requests?

Submit

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