Please respond to the questions below, so we may keep you and other congregants gathering with you safe and healthy. These questions are to screen for persons who could transmit the virus causing COVID-19. Your information will remain confidential. The District Superintendent, Bishop/Cabinet, and Department of Health will review only if necessary. The form is effective for 7 days from the time it is completed.
Alternative Options:
- Print a blank copy of the form and return your completed form to the church office before you plan to attend worship or a gathering.
- If you do not own a computer or printer, please call the church office and provide the information to the questions on the telephone.
I acknowledge:
1. I have not had two (2) or more of the following symptoms of COVID-19 in the past 14 DAYS:
a. Fever
b. Shortness of breath or difficulty breathing
c. Chills
d. Persistent cough
e. Flu-like symptoms
f. Diarrhea or intestinal upset
g. Fatigue
h. Sore throat
i. Headache
j. Muscle pain
k. Recent loss of taste or smell
2. I have not been in contact with anyone experiencing symptoms of COVID-19 identified above in the past 14 days.
3. I have not tested positive for COVID-19, nor am I awaiting test results, nor have I tested positive for COVID-19 and have not subsequently had complete resolution of COVID19 symptoms.
4. I will immediately notify my local clergy (either Pastor Abi or Pastor Arum) if after attending In-Person Worship or any other STUMC gathering, I develop two (2) or more symptoms of COVID-19; and I will avoid contact with others and seek appropriate medical attention.
If you cannot answer ‘YES’ to all of the above, we ask you to wait before attending
Furthermore, I will comply with the expectations outlined by the Healthy Church Team during all activities (wearing a mask onsite, observing social distancing, etc.). I understand that if I do not comply, I will first be asked to follow the guidelines for the health and wellbeing of all participants, and then if unwilling to comply, I will be asked to leave or the activity will be stopped altogether.
submit
Thank you for completing our Health Form to help ensure everyone’s safety. If you have any questions or problems, please contact Samantha Bouquet , Administrative Assistant, or Pastor Abi at the church office during business hours by email or phone, 703-368-5161.
Everyone should check their temperature immediately before coming to church for their event. If you are running a fever or develop any other symptoms of COVID-19 you may not attend the event.
