COVID-19 Form for Hope Community Church

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Voluntarily reporting personal health information regarding potential community transmission of infectious disease is understood as consent to disclose anonymized data to any parties that may have been affected. A person who has COVID-19 symptoms or test results will be asked for permission before sharing any non-anonymous details with the congregation. Officers and staff may be privy to this information regardless of prior consent.

Email *

Phone Number

Are you reporting for yourself or someone else? *

Myself

Someone else

Name *

What in-person Hope event did you attend? *

What date did you attend that event? *

YYYY

Are you currently experiencing COVID-19 symptoms? *

These include: Fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, or diarrhea.

Yes

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