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Covid-19 Contact information
House of the Lord - Attendance
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Date of Church Attendance
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MM
/
DD
/
YYYY
Surname
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Name
*
Your answer
Phone number
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Email
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Address
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No of persons attending with you
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1
2
3
4
5
None
Temperature (to be filled in at the church)
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DO YOU SUFFER FROM ANY OF THESE SYMPTOMS? Fever, cough, sore throat, shortness of breath difficulty breathing, body aches, loss of smell or taste, nausea, vomiting, diarrhoea, fatigue, weakness
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No
Yes
Any other Information or Comments
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