Middlebury Congregational Church Worship Registration Form - June 13
Sunday, June 13 at 10 am, Sanctuary
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Email *
Name of person filling out form *
Phone Number *
Name(s) of People in Household Planning to Attend Service *
Sunday School: Name(s) of Children in Household Planning to Attend Sunday School (Outdoors, Sunday school canceled in case of poor weather)
Nursery Care: Names & Ages of Children Requiring Outdoor Nursery Care (Preschool Playground is Nursery Location, Rain Location is Indoors)
COVID Screening Checklist
In the last 14 days I (or anyone in my household) HAVE NOT:
* Experienced any of the following: fever, chills, body aches, flu-like symptoms, cough, shortness of breath, loss of smell or taste, weakness.
* Knowingly had close contact with anyone who has tested positive for COVID-19.

In attending worship services I AGREE TO:
* Wear a mask during worship and/or Sunday School.
* Notify the church (within 14 days after the service) if I learn that I (or a member of my household) has been exposed to someone who tested positive for COVID-19 or if I test positive.

Out of the consideration of others, I agree to STAY HOME if I (or anyone in my household) between the time of filling out this form and the date of worship:
* Experience any new symptoms listed above.
* Knowingly have close contact with anyone who has tested positive for COVID-19.
* Fall into the CT requirements for quarantine (recent travel, etc.).
Sign the form by typing your name. By signing, you agree to honor the COVID Screening Checklist above. *
A copy of your responses will be emailed to the address you provided.
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