Liturgy Registration Form
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Household Information
*
Please select the applicable one for you
Yes
No
Don't want to answer
Not Applicable
Have you had the corona vaccine?
1
2
3
4
Have you had corona recently?
5
6
7
8
Have you shown signs of corona recently( Fever,Cough, Difficulty breathing, etc.)
9
10
11
12
Have all of your family had the corona vaccine?
13
14
15
16
Have you or is anyone in your household above the age of 65, pregnant or suffering from any pre-existing medical conditions (heart diseases, lung diseases, endocrine disorders, etc.)
17
18
19
20
Please select all the suitable days and times for you to schedule Liturgy.
*
Date
-
Month
-
Day
Year
Date
Signature
Submit
Should be Empty: