Health Acknowledgement

Please fill out this form and click submit.

This form will be effective for seven days after today's date. You will be asked to confirm that the information you have provided is still accurate when you arrive for  your gathering or event. Please complete a new form for each service, event, or meeting you plan to attend.

Please select all that apply.
Please respond to the following questions, 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. The information will remain confidential and reviewed only by your local clergy. The District Superintendent, Bishop/Cabinet, and Department of Health will review only if necessary.

I acknowledge:

1. I am not experiencing two or more of the following symptoms of COVID-19:
        Fever (100 F or higher) or chills
        Shortness of breath or difficulty breathing
        New loss of taste or smell
        Muscle or body aches
        Sore throat
        Congestions or runny nose, not allergy related
        Nausea or vomiting

2. I have not been in contact with anyone experiencing symptoms of COVID-19 (see #1) or I am fully vaccinated (14 days after series of vaccinations are completed.)

3. I have not tested positive for COVID-19, nor am I awaiting test results.

4.  If I have tested positive for COVID-19, I have complete resolution of symptoms OR (if asymptomatic) have completed 10 days of self-isolation.

5. I will immediately notify the pastor if within 5 days after attending this event I develop 2 or more symptoms of COVID-19, will avoid contact with others and will seek medical attention.
Please select one option.
If you cannot answer ‘YES’ to all of the above, we ask you to wait before attending any in-person gatherings at church until you can answer affirmatively.


Please fill out this form and click submit.