EBC JAZZ VESPERS HEALTH FORM- NYE EVENT FEATURING ANTONIO HART

Full Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Format: (000) 000-0000.

E-mail

example@example.com

ALL THE QUESTIONS BELOW MUST BE ANSWERED BEFORE YOU ARE ALLOWED TO ATTEND THIS SERVICE.

The questions and answers provided here are intended to help find ways to aid in providing you and your family members the best protection in lowering the risk of introducing and spreading COVID-19. AGES18+ MUST COMPLETE THIS FORM

THIS FORM DOES NOT ACT AS REGISTRATION FOR ATTENDANCE TO EBC WORSHIP SERVICES - PLEASE REGISTER AT bit.ly/EBCREOPENS

BY ATTENDING AND/OR PARTICIPATING IN THIS WORSHIP SERVICE, YOU ARE DEEMED TO HAVE GIVEN A FULL RELEASE OF LIABILITY TO EMMANUEL BAPTIST CHURCH AND ITS EMPLOYEES/VOLUNTEERS TO THE FULLEST EXTENT PERMITTED BY LAW.

Have you or anyone in your household had any of the following symptoms in the last 14 days: sore throat, cough, chills, body aches for unknown reasons, shortness of breath for unknown reasons, loss of smell, loss of taste, fever at or greater than 100 degrees Fahrenheit? CHECK ONE:*

YesNo

Have you or anyone in your household traveled outside of U.S. within the last 14 days? CHECK ONE:*

YESNO

Do you have any reason to believe you or anyone in your household has been exposed to or acquired COVID-19 within the last 14 days? CHECK ONE:*

YESNO

To the best of your knowledge have you been in close proximity to any individual who tested positive for COVID-19 within the last 14 days? CHECK ONE:*

YESNO

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EBC JAZZ VESPERS HEALTH SURVEY: