RECENT CONTACTS AND EXPOSURE: In the last 14 days, have you been exposed to others who are known to have COVID-19? (Please check all that apply.) *
LONG TERM CARE FACILITY: Do you live in a long-term care facility; this includes nursing homes and assisted living facilities? *
MEDICAL FACILITIES: Do you work in a medical facility? (Hospital, Emergency Room, other medical setting, long-term care facility) *
Name or RBC Envelope Number *
Mobile Phone Number
GUIDELINES CONFIRMATION: By submitting this form, I understand and agree to comply with the safety guidelines that include social distancing and required face coverings as mandated by the Rehoboth Baptist Church and the District of Columbia. *
A copy of your responses will be emailed to the address you provided.