Collier Street United Church - October 2021 - In-Person Worship Pre-Screening Questionnaire
Please sign-up to attend In-Person Worship during the month of October 2021, select each week you plan to attend and complete the pre-screening questionnaire.

Requirements are: wear a mask, maintain physical distancing, check-in at reception, present your vaccination certificate, have your temperature taken, follow directions, enjoy the service, and be kind - we're all in this together!

Please log attendees from your own household/social circle only. All others need to be screened separately. Thank you for your cooperation and understanding.
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Email *
Last Name(s) of all those attending from your household: *
First Name(s) of all those attending from your household: *
Total Number Attending from your household: *
Please select the worship service(s) you would like to attend during October 2021: *
In-Person Worship Pre-Screening Questionnaire:
Please complete the following questions.
Fever or Chills? *
New or worse cough, shortness of breath, difficulty breathing? *
Fatigue, muscle or body aches, headache? *
Decrease or loss of sense of smell or taste? *
Runny nose, sneezing, nasal congestion? *
Sore throat, difficulty swallowing, hoarse voice? *
Diarrhea, nausea, vomiting? *
Unexplained fatigue, malaise, abdominal pain? *
Travel or contact with COVID-19 or ARI positive person? *
ARI = Acute Respiratory Infection
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