First Pres COVID-19 Health Screen Form
Please complete this Health Screen Form before entering campus.
If you answer YES to questions 1-3, please DO NOT enter campus.

While on campus, please keep safe practices—including wearing a mask and maintaining 6 ft. social distance.

Thank you from all of us at First Pres Berkeley!

Sign in to Google to save your progress. Learn more
Your Name *
Your email address *
Date on Campus *
MM
/
DD
/
YYYY
1.  Have you been diagnosed with COVID-19 or had a test confirming you have the virus within the last 10 days? *
2.  Do you live in the same household or been in close contact (six feet) with someone who has tested positive for the virus or been in isolation for COVID-19, in the past 14 days ? *
3.  Today, or within the past 24 hours, have you had any of these symptoms, which is new or not explained by a reason other than possibly having COVID-19: fever, chills, cough, sore throat, shortness of breath, difficulty breathing, unusual weakness or fatigue, loss of taste or smell, muscle pain, headache, runny/congested nose, diarrhea, nausea/vomiting? *
Liability Release
As I enter the First Presbyterian Church of Berkeley campus, I promise to abide by all policies, procedures, and protocols in place during the COVID-19 pandemic in accordance with the sheltering orders by Alameda County, City of Berkeley, State of California. I agree to hold harmless and indemnify the First Presbyterian Church of Berkeley, and its officers and board members, for any and all claims now or in the future, which may arise as a result of me or anyone in my family or friendship networks who contract COVID-19 or any related virus due directly to or due indirectly to being on the First Pres campus. I release any and all rights to make a claim or file a lawsuit against the First Presbyterian Church of Berkeley, and its officers and board members for such related illness as specified above.
I read and fully understand the above terms, and sign this voluntarily. This agreement shall not be modified orally by anyone. *
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy