Faith Church Re|Gather (health and travel form)
I hereby certify, represent, and warrant as follows.

Within the last fourteen (14) days of this health and travel form, I/WE HAVE NOT:

- tested positive or presumptively positive with the Coronavirus or been identified as a potential carrier of the Coronavirus or similar communicable illness
- experienced any symptoms commonly associated with the Coronavirus
- fever (temperature above 37.8 C)
- shortness of breath
- runny nose/sneezing without other known cause
- headache
- chills
- sore throat
- stuffy or congested nose
- digestive issues (nausea/vomiting/diarrhea)
- cough (new or worsening)
- difficulty swallowing
- loss sense of taste or smell
- pink eye (conjunctivitis)
- barking cough
- hoarse voice
- fatigue/malaise/muscle aches (unexplained)
- been outside of Canada
- been in direct contact with or the immediate vicinity of any person I/WE knew and/or now know to be carrying the Coronavirus or has traveled outside of Canada within the last fourteen (14) days
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Phone No. *
Email *
Date of Signature *
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Signature (Digital - Type Full Name) *
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