Back-to-Church Registration Form
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
You are a
Member
Visitor
Have you been fully vaccinated for COVID-19?
Yes, I have received both.
No, I have received only one vaccine.
No
Will other people be attending worship service with you?
Yes
No
Please give details about the people attending with you
Do you have any health conditions?
Yes
No
Please give details about your underlying health conditions
Emergency Contact Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
I, undersigned, agree with the statements selected below:
I understand while participating in in-person events, I will be required to wear a face covering at all times.
I am also required to practice social distancing to reduce the spread of COVID-19.
I understand that if I don't adhere these rules, I will be requested to leave the campus.
I understand my entry will be denied, if I am unable and/or refuse to provide proof of vaccination upon my arrival.
I understand the Church and all affiliates will not be responsible in any manner for any risks related to COVID-19 in connection with in-person events resuming. I am returning to in-person events at my own risk and fee will. I hereby release the Church, and its current officers, employees, members, volunteers, representatives, and affiliates from any and all liabilities, claims, litigation, causes of action of any nature which may be incurred, directly or indirectly, now or in the future, in any way related to COVID-19.
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
Submit
Should be Empty: