January 2021 10:30am Contemporary Services - Registration

Please fill out this form and click submit.
Please be sure to arrive no earlier than 15 minutes before service.
Masks must be worn at all times.

Name

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Email

This address will receive a confirmation email

Phone

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Number of Attenders

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Dates attending

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Please select all that apply.

1/3/21 1/10/21 1/17/21 1/24/21 1/31/21

Screening Questions

1. Have you (or anyone in your household) experienced any symptoms of COVID-19 such as cough, shortness of breath or fever within the past 14 days?

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Please select all that apply.

Yes No

2. Have you (or anyone in your household) been in physical contact with anyone who has tested positive for COVID-19 or has otherwise unexplained symptoms of COVID 19 such as cough, shortness of breath, fever, within the past 14 days?

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Please select all that apply.

Yes No

3. Have you (or anyone in your household) tested positive for COVID-19 or experienced otherwise unexplained shortness of breath, cough, fever, or other flu-like symptoms in the past 14 days?

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Please select all that apply.

Yes No

If yes to any of the above, please explain.

Description

Please fill out this form and click submit.
Please be sure to arrive no earlier than 15 minutes before service.
Masks must be worn at all times.

Please Fix the Following

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