COVID- 19 Contact Tracing Register

COVID-19 SALAAH REGISTRATION FORM
Please complete this form to register for salaah, when you arrive at the mosque wash hands with hand sanitiser.
Name*

First NameMiddle NameLast Name
D.O.B*

DayMonthYear
Date
As per government regulation people under the age of 13 and over the age of 65 are not allowed to attend prayers.
Gender*

MaleFemale
National I.D/Passport No (Under 18 indicate N/A)*
Phone Number*
Nationality *
Other Nationality Specify
Email*
example@example.com
Estate*
Street *
County*
Next of Kin Details *

First NameLast Name
Phone Number*
Email (optional)
example@example.com
Have you had COVID-19 symptoms in the last 14 days?*

YESNO
Take Photo (Optional)
Upload Image (Optional)

Browse Files

Cancelof
Upload Image (Optional)
Kindly accept Terms and Conditions as per government regulation. Please consent parklands Mosque to send you information on the mosque activities and Dawah.*

Accept Terms
Temperature Check

YESNO
Personal Pin identification
Should be Empty: