Attestation Form

At this time, all worship service and program attendees are required to fill out this attestation form every time they attend a service or program. Please complete this form within 24 hours of the service or program you are attending. You will receive a confirmation email that you can show to check-in staff in lieu of completing a paper form on site. Thank you, in advance, for completing this form as this will allows us to check-in attendees more quickly.

* First Name

* Last Name

* Date of Visit

* Time of Visit

* Name of Event Visit

* Cell Phone

* Email Address

* Are you experiencing any of the following symptoms?

* Have you been tested and had a positive result, or have you been told by a healthcare provider that you are likely positive for COVID-19?

* Within the last 14 days, have you been in close contact with anyone that you know has been diagnosed with COVID-19 or has had COVID-19 related symptoms?

* Are you a healthcare worker who has had contact with a COVID-19 positive individual as part of your work?

* Do you agree to wear Personal Protective Equipment (PPE) while engaging in activities on site?

* Do you agree to adhere to all rules and protocols of social / physical distancing while engaging in activities on site?

* Date of Signing

* Time

* Signature [TYPE YOUR NAME]

Mon, June 30 2025 4 Tammuz 5785