Clear View Baptist Church
Date: May 9, 2021 (Mother’s Day)
Time: 11:00 A.M.
Location: 314 Hobson Street, Newark, NJ 07112
Contact: (973)926-0471 or
First and Last name
Have you tested positive for COVID-19 within the past 14 days?
Have you been exposed to someone that has tested positive for COVID-19 within the past 14 days?
In the past 14 days have you had any of the following symptoms? (check all that apply)
Shortness of Breath or Difficulty Breathing
Loss of Taste or Smell
Congestion or Runny Nose
Nausea or Vomiting
A copy of your responses will be emailed to the address you provided.
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service