Rehoboth Baptist Church COVID-19 Health Form
(Please complete prior to attending services and update weekly)
Email address *
Desired date to attend in person service? *
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How many seats are needed? *
PRESENT HEALTH CONDITION: Have you recently experienced any of these symptoms? (Please select all that apply) *
Required
UNDERLYING HEALTH CONDITIONS: Do you have an underlying health condition listed below that may place you at greater risk for COVID-19? (Please select all that apply) *
Required
INTERNATIONAL TRAVEL: In the last 14 days have you traveled internationally, meaning outside of the United States? *
RESTRICED TRAVEL: In the last 14 days have you traveled to any of the states listed on the DC or State of Maryland Quarantine list of “Hot Spots” that require you to self-quarantine for 14 days? A link for the Mayor's most recent listing of high-risk states can be found on https://coronavirus.dc.gov/release/dc-health-releases-list-high-risk-states. *
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.) *
Required
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
Date *
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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.
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