Pre-Entrance Questionnaire
Email address *
Last Name *
First Name *
Planned Date of Arrival *
Scheduled Time *
Phone Number *
Reason for Being Onsite *
In the last 14 days, have you or a member of your household been in close contact (within six feet) of someone who suspects they have the Coronavirus? *
In the past 14 days, have you or a member of your household tested positive for Coronavirus ? If yes, you are encouraged to self Isolate/quarantine at home. *
In the past 14 days, have you traveled outside of your hometown to any foreign country or area within the U.S. with a CDC Level 3 travel notice or similar State notice? A Level 3 travel notice is a "widespread ongoing transmission with OR without restrictions on entry to the United on entry to the United States." *
Check only symptoms exhibited within the last 14 days, that are of unknown origin. *
I acknowledge and understand there is an increased risk that COVID-19 can be transmitted in any place of public accommodation, including First Mount Zion Baptist Church. FMZBC seeks to protect its employees, members, and servant volunteers who work, attend, serve, and visit here by adhering to CDC and the Commonwealth of Virginia guidelines for mitigating the transmission of COVID-19. By entering the premises I agree to assume these risks. As a precondition of entering the premises, I have confirmed that my answers to this questionnaire are complete, true and accurate. *
I agree to the following *
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy