Health Screening Form

I am completing this form on behalf of my child *

Yes

No (I am completing in my personal capacity)

Full Name *

First Name

Last Name

I have completed the Personal Data form *

If you have not yet filled in the Personal Data form, please do so by Messaging the GC Whatsapp Number 0832611724 and type 6 to get the link.

Yes

No

Reason for entry *

Please select from the options below to indicate why you are coming to church

Prayer Meeting

iGroup Meeting

Private Meeting

Band Recording/Practice

Online Recording

Leadership Meeting

Other

Have you travelled internationally in the last 14 days *

Yes

No

Have you had close contact with anyone who is COVID positive *

Yes

No

Are you experiencing any of the following symptoms? *

Please select which one applies to you

Fever

Cough

Shortness of Breath

Sore Throat

Body Pains

Headache

Severe Fatigue

Loss of Taste or smell

Vomiting or diaorhea

None of the above

I understand that if I am over 60 or have underlying health issues that I am at high risk *

Please note that if you fall into this category, we do encourage you to rather stay home at this time to avoid risk of exposure.

Yes

No

I agree to wear a mask at all times *

Yes

No

I agree to social distancing practices as stipulated by the Health Dept. of South Africa *

Yes

No

I understand that if I bring children to a meeting, I am responsible for their care and will make sure they follow the Health dept. Guildlines

Yes

No