COVID-19 Activity Form

NORTH HILLS COMMUNITY BAPTIST CHURCH
SCREENING FOR COVID-19 EXPOSURE

Please complete this form within 24 hours of the time you are scheduled to serve or meet.

Have you been exposed to someone who has been diagnosed with COVID-19 in the past 14 days?
YESNO

Has anyone in your family been sick with a fever, cough, or shortness of breath in the past 14 days?
YESNO

Do you have a fever (greater than 100.4 F), difficulty breathing/shortness of breath, new cough, sore throat, headache, muscle aches, chills, or loss of smell or taste?
YESNO

If you have answered YES to any of these questions, please contact the leader who has scheduled you and refrain from serving or attending.

Please understand that you will be required to wear a mask or face covering throughout your time of meeting in person.

Activity Organizer
—Please choose an option—Tim SpringBeth SpenceChristine O'NeilHeidi ClarkLori TissueBrianne ClausAmy MendicinoBill SundermanPauline SpringLynn BerneyKendra DetwilerOther

[group other-organizer]
Other Organizer:
[/group]

Meeting/Activity Date

When completing this form online, the information below will be considered your electronic signature.

Participant Name

If a minor, Parent/Guardian

Email

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