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Feet Washing and Communion Service
April 1, 7:30pm
Pre-Screening Questionnaire
The information you provide for this screening will be kept confidential and secure and will only be used as needed to protect the health and safety of our members and the public , in accordance with our COVID-19 Privacy Notice.
As Identified by the CDC, possible COVID-19 symptoms include fever, chills, cough, shortness of breath or difficulty breathing, loss of sense of smell or taste, fatigue, muscle or body aches, headache, sore throat, congestion or runny nose nausea or vomitting and.or diarrhea. Are you experiencing any of the COVID19 symptoms listed above, which are new or not typical for you?
Yes
No
Have you had a fever (above 100.0 degrees Fahrenheit) today?
Yes
No
Have you or anyone in your household been tested or treated for COVID-19 in the past 14 days?
Yes
No
Close contact is defined as someone who was within 6 feet of a person with known COVID19 (without proper PPE) for a sum total of 15 minutes or more over a 24 hour period. Have you been in close contact with anyone who has tested positive for COVID19 that has not been reported.
Yes
No
In the past 10 days, have you or anyone in your household traveled outside of Maryland (PA, DE, DC, VA, WV Excluded)?
Yes
No
Have you or anyone in your household participated in group activities that carry high exposure risks?
Yes
No
First Name
Last Name
Email
Phone Number
What church do you attend and your Pastor's name?
If any children will be attending with you, please register them below:
First Child Name
Last Name
Age Group
Toddlers (2-3)
Preschoolers (3-5)
Middle Childhood (6-8)
Middle Childhood (9-11)
Young Teens (12-14)
Teenagers (15-17)
Second Child First Name
Last Name
Age Group
Toddlers (2-3)
Preschoolers (3-5)
Middle Childhood (6-8)
Middle Childhood (9-11)
Young Teens (12-14)
Teenagers (15-17)
Third Child First Name
Last Name
Age Group
Toddlers (2-3)
Preschoolers (3-5)
Middle Childhood (6-8)
Middle Childhood (9-11)
Young Teens (12-14)
Teenagers (15-17)
Fourth Child First Name
Last Name
Age Group
Toddlers (2-3)
Preschoolers (3-5)
Middle Childhood (6-8)
Middle Childhood (9-11)
Young Teens (12-14)
Teenagers (15-17)
Submit Your Registration
