Registration for 5/21/22 In-Person Service @ Kehilat Shalom

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A copy of this form must be filled out for EACH individual attending the service. If a couple or parent and child are attending together, please fill out this form TWICE, once with each name.

Email *

Name *

Preferred phone number *

I am fully vaccinated (at least 14 days past my second Pfizer or Moderna vaccine or my one-dose Johnson & Johnson vaccine.) *

Yes

Required

If not fully vaccinated, I have been told by my physician that vaccination is medically contraindicated for me. (If you are fully vaccinated skip this question.)

Yes

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If not fully vaccinated due to medical reasons, I agree to both wear a mask and sit in the socially distanced section. (If you are fully vaccinated skip this question.)

Yes

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I agree to sit where instructed by the usher or Rabbi *

Yes

I affirm that I will not attend if I have a fever or other signs of COVID-19 or if I am feeling ill on the morning of the service *

Yes

I affirm that I have read and understood the regulations posted at https://docs.google.com/document/d/1BLT6at55Fb8ZAKdGjLf6ZnvZe5UyqaGzMakBRId4yLc/edit?usp=sharing and I agree to abide by them. *

Yes

Required

A copy of your responses will be emailed to the address you provided.

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