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
* Required
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I certify that the above is true
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Event
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Choose
Sunday Worship Together In Person (Mar 7, 2021)
Sunday Worship Together In Person (Mar 14, 2021)
Sunday Worship Together In Person (Mar 21, 2021)
Sunday Worship Together In Person (Mar 28, 2021)
Location
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Faith Church (15 Olive Ave.)
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Name(s)
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Your answer
Phone No.
*
Your answer
Email
*
Your answer
Signature (Digital - Type Full Name)
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Your answer
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