WOGC Self Assessment Questionnaire

Please complete this form prior to entering and/or attending church services at the WOGC on SUNDAY MORNING. Thank you in advance for your cooperation as we strive to keep you safe.

Your First & Last Name/Family's Name (i.e., Newton Family). **Please note that this questionnaire can be used for your entire family or for an individual.** *

If you are completing this questionnaire for more than one person, please list their names here:

How many people are accompanying you today for service? (Select the TOTAL number of people, including yourself, i.e. you and 2 other people = 3) *

1. Do you/anyone with you have a fever? *

Yes

2. Do you/anyone with you have a worsening cough? *

Yes

3. Do you/anyone with you have shortness of breath? *

Yes

4. Do you/anyone with you have a sore throat? *

Yes

5. Do you/anyone with you have diarrhea? *

Yes

6. Have you/anyone with you had close contact with an individual who has tested positive for COVID-19 within the past 14 days? *

Yes

7. Have you/anyone with you traveled via airplane internationally or domestically in the past 14 days? *

Yes

ELECTRONIC SIGNATURE: PLEASE TYPE YOUR FIRST AND LAST NAME. Your completion of this questionnaire and electronic signature below releases the Word of God Church from any form of liability of injury or illness you/anyone with you may experience while on campus. (*The person completing this form should type in their first and last name.) *

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