Church Attendance Registration Form
Please fill in the form below.
Full Name
*
First Name
Last Name
Email
example@example.com
Phone Number
*
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
I will attend:
*
How many will be attending with you? (not including yourself)
*
5 people maximum in family
Names of Your Attendees:
First and Last Name
Attestation:
*
I WILL wear a face mask at all times while on church premises.
I WILL keep a safe distance of at least 6 feet from other people.
I have NOT experienced any symptoms of COVID-19 in the past 14 days (fever, cough, shortness of breath or difficulty breathing, chills, repeated shaking with chills, muscle pain, sore throat, abdominal pain/diarrhea, or new loss of taste or smell).
I have NOT been in close or proximate contact in the past 14 days with anyone who has tested positive for COVID-19 or who has had symptoms of COVID-19.
I have NOT traveled to any of the states listed in Governor Cuomo's Executive Order 205 or any international destinations requiring quarantine (as identified by New York State).
I did NOT test positive for COVID-19 in the past 14 days.
Required Protocol for Returning On-Site (n.b. you must read all text and scroll to the bottom before you can use the checkbox)
*
Signature
*
Clear
Notes:
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