COVID-19 Screening Form for St. Mary Great Mother of God Catholic Church
Please complete this form before attending an in-person faith formation class/activity at St. Mary Great Mother of God.
Full Name *
email address *
Have you been diagnosed with COVID-19 in the last 14 days? *
Have you come in to close contact (within 6 feet for longer than 15 minutes) with anyone who has been diagnosed with COVID-19? *
Do you have a temperature of 100.4 F or greater? *
Are you currently experiencing COVID-19 symptoms, including fever, cough, sore throat, respiratory illness, shortness of breath, diarrhea, or any other cold/flu symptoms? *
I hereby certify that the all of my responses are accurate to the best of my knowledge. *
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