TimeOut Pre-Registration

Pre-Registration

Time Out is on the 2nd & 4th Saturday of every month from 2 pm to 5 pm, at Healing Waters Worship Center located at 12172 Smith's Neck Road, in Carrollton, VA
Parent Name

First NameLast Name
Child's Name

First NameLast Name
How old is your child?
In the last 48 hrs has this child been experiencing any physical discomfort such as chills, cough, difficulty breathing, fatigue, body aches, headaches, loss of taste or smell, sore throat, congestion, runny nose, nausea, vomiting or diarrhea?

yesno
Has this child been exposed to someone with a diagnosis or suspected case of Covid-19 at anytime in the last 14 days?

yesno
Has this child traveled outside of the country in the last 14 days?

yesno
Do you give us consent for the treatment of minor scrapes or bumps that may occur in children’s spaces?

YesNo
Do you have another child that you would like to pre-register?

yesno
Child's Name

First NameLast Name
How old is your child?
In the last 48 hrs has this child been experiencing any physical discomfort such as chills, cough, difficulty breathing, fatigue, body aches, headaches, loss of taste or smell, sore throat, congestion, runny nose, nausea, vomiting or diarrhea?

yesno
Has this child been exposed to someone with a diagnosis or suspected case of Covid-19 at anytime in the last 14 days?

yesno
Has this child traveled outside of the country in the last 14 days?

yesno
Do you give us consent for the treatment of minor scrapes or bumps that may occur in children’s spaces?

YesNo
Do you have another child that you would like to pre-register?

yesno
Child's Name

First NameLast Name
How old is your child?
In the last 48 hrs has this child been experiencing any physical discomfort such as chills, cough, difficulty breathing, fatigue, body aches, headaches, loss of taste or smell, sore throat, congestion, runny nose, nausea, vomiting or diarrhea?

yesno
Has this child been exposed to someone with a diagnosis or suspected case of Covid-19 at anytime in the last 14 days?

yesno
Has this child traveled outside of the country in the last 14 days?

yesno
Do you give us consent for the treatment of minor scrapes or bumps that may occur in children’s spaces?

YesNo
Do you have another child that you would like to pre-register?

yesno
Child's Name

First NameLast Name
How old is your child?
In the last 48 hrs has this child been experiencing any physical discomfort such as chills, cough, difficulty breathing, fatigue, body aches, headaches, loss of taste or smell, sore throat, congestion, runny nose, nausea, vomiting or diarrhea?

yesno
Has this child been exposed to someone with a diagnosis or suspected case of Covid-19 at anytime in the last 14 days?

yesno
Has this child traveled outside of the country in the last 14 days?

yesno
Do you give us consent for the treatment of minor scrapes or bumps that may occur in children’s spaces?

YesNo
Do you have another child that you would like to pre-register?

yesno
Child's Name

First NameLast Name
How old is your child?
In the last 48 hrs has this child been experiencing any physical discomfort such as chills, cough, difficulty breathing, fatigue, body aches, headaches, loss of taste or smell, sore throat, congestion, runny nose, nausea, vomiting or diarrhea?

yesno
Has this child been exposed to someone with a diagnosis or suspected case of Covid-19 at anytime in the last 14 days?

yesno
Has this child traveled outside of the country in the last 14 days?

yesno
Do you give us consent for the treatment of minor scrapes or bumps that may occur in children’s spaces?

YesNo
Do you have another child that you would like to pre-register?

yesno
Child's Name

First NameLast Name
How old is your child?
In the last 48 hrs has this child been experiencing any physical discomfort such as chills, cough, difficulty breathing, fatigue, body aches, headaches, loss of taste or smell, sore throat, congestion, runny nose, nausea, vomiting or diarrhea?

yesno
Has this child been exposed to someone with a diagnosis or suspected case of Covid-19 at anytime in the last 14 days?

yesno
Has this child traveled outside of the country in the last 14 days?

yesno
Do you give us consent for the treatment of minor scrapes or bumps that may occur in children’s spaces?

YesNo
Thank you so much for Pre-Registering your child(ren). This will help check-in go much more quickly on Saturday afternoon. See you soon!
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