Health Assessment | Online Sunday Service

SUNDAY SERVICE REGISTRATION

Health Assessment Form

To be able to manage our services in a safe and orderly manner, please answer the health assessment questions before proceeding to registration. One registration per person. There are limited slots per service. Once a service is filled, you may choose another service schedule. We will also not allow any walk-ins.

Are you a Pastoral Staff? *

1. Are you below 18 years old? *

2. Are you above 65 years old? *

3. Do you have AT LEAST ONE of the following conditions: *

Hypertension
Diabetes
Heart Disease
Lung Disease (Asthma, COPD)
Cancer
Chronic Kidney Disease
Pregnancy
None of the above

4. Did you travel abroad within the last 14 days? *

5. Within the last 14 days, have you had contact with or exposure to a confirmed or probable case of COVID19? *

6. In the last 14 days, did you have AT LEAST ONE of the following symptoms: *

Fever (37.7c)
Cough
Colds
Sore Throat
Shortness of breath/Difficulty breathing
Diarrhea
Weakness or fatigue
Vomiting
None of the above

7. Is there anyone in your household who has exhibited any of the symptoms in question no. 6 within the last 14 days? *

8. Have you tested POSITIVE for COVID-19 within the last 14 days (testing may either be through oral/nasal swab or blood extraction)? *

9. I hereby authorize New Life to collect and process the data indicated herein for the purpose of implementing control and/containment of COVID-19. I understand that my personal information is protected by RA 10173, Data Privacy Act of 2012, and that I am required by RA 11469, Bayanihan to Heal as One Act, to provide truthful information. That I am aware of the implications if any statement is not honestly stated and that there are legal actions to be taken in responsibility to myself and the company I represent. *

Sunday Service Time *

10:30AM
3:00PM

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