Church Service Registration – Mount Lebanon Baptist Church

There will be COVID-19 Screening Prior To Entering

Name *

First

Last

Phone Number *

Email *

How Many Attending *

Name Of Attendees If More Than One

Which Day Will You Be Attending? *

1. Do you have any of these symptoms that are not caused by another condition? *

• Fever or chills • Cough • Shortness of breath or difficulty breathing • Fatigue • Muscle or body aches • Headache • Recent loss of taste or smell • Sore throat • Congestion • Nausea or vomiting • Diarrhea

2. Within the past 14 days, have you had contact with anyone that you know had COVID-19 or COVID-like symptoms? Contact is being 6 feet (2 meters) or closer for more than 15 minutes with a person, or having direct contact with fluids from a person with COVID-19 (for example, being coughed or sneezed on). *

3. Have you had a positive COVID-19 test for active virus in the past 10 days? *

4. Within the past 14 days, has a public health or medical professional told you to self-monitor, self-isolate, or self-quarantine because of concerns about COVID-19 infection? *

5. Are you currently waiting on the results of a COVID-19 test? *

6. Have you or anyone in your household traveled outside of the state or country in the last 14 days? *

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