Hyde Park Union Church Registration and Pre-Screening Form
We are excited to have you with us for in-person worship! To help us prepare for Sunday, prevent the spread of COVID-19 and reduce the risk of exposure, we are conducting a simple screening questionnaire. Your participation will help us take precautionary measures to protect you and everyone that enters HPUC. We will also be using this form to contact trace our in-person worship, so please fill this out prior to arriving at the church. Thank you for your cooperation!
Household name *
How many people in your household are attending in-person worship? *
Phone number *
Today's date *
MM
/
DD
/
YYYY
Does anyone in your household have a fever or felt hot or feverish recently (14-21 days)? *
Has anyone in your household experienced shortness of breath or difficulties breathing? *
Does anyone in your household have a cough? *
Does anyone in your household have any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue? *
Has anyone in your house experienced recent loss of taste or smell? *
Has anyone in your house been in contact with someone that has COVID-19 recently (14-21 days)? *
Has anyone in your household traveled in the past 14 days to any regions with a COVID-19 travel advisory? *
If you have answered yes in response to the COVID-19 symptom questions, have you tested negative for COVID since your symptoms emerged?
Clear selection
Is your household fully vaccinated - children under 16 excluded? (Optional)
Clear selection
Finally, do you have any prayer requests?
Submit
Never submit passwords through Google Forms.
This form was created inside of Hyde Park Union Church. Report Abuse