Wells Memorial COGIC - COVID Screening Assessment

Wells Memorial COGIC

Screening Assessment for COVID Exposure
Date you will attend in person service *

Month Day Year
Date
Your Full Name *
First Name and Last Name
Email *
example@example.com
Phone Number *

Area Code Phone Number
Temperature
Have you traveled by public transportation in the past 14 days (bus, train, airplane, etc)? *

Yes No
Have you traveled outside of the country recently? *

Yes No
Do you have or have you had a fever, cough, or new shortness of breath within the past 14 days? *

Yes No
Have you been to the emergency room within the past week? *

Yes No
Have you tested positive for COVID-19? *

Yes No
Have you had close contact with a lab confirmed COVID patient, or has anyone in your home been diagnosed with COVID-19? *

Yes No
*A mask is required to be worn over your mouth and nose while you are within the church and on the grounds
*Use hand sanitizer when entering the sanctuary
*Remember social distancing
*Please follow the directions of the ushers/deacons
Please sign your name electronically if you agree to the Worship Release Form *
God Bless You! We are believers and believe in the healing power of Jesus Christ. If you have been exposed to COVID-19 and exhibiting cold or flu-like symptoms, we strongly encourage you to stay home and tune in to the live worship service on Facebook Live and YouTube Live or by visiting the church website at www.wellsmemorialcogic.org
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