Re-Entry Registration Form - Mount Ephraim Baptist Church

Name *

Date of Service *

May 29, 2022

Do you currently have or recently had (within the last 14 days) : *

Have you been vaccinated? *

Yes
No

Within the last 14 days, have you OR anyone in your household traveled to any areas currently affected by coronavirus (overseas/domestic): *

Yes
No

Within the last 14 days, have you OR anyone in your household had any contact with someone who was confirmed positive or suspected to have coronavirus or COVID 19: *

Yes
No

Are you taking any fever-reducing medicines? *

Yes
No

Have you been directed to self-quarantine by a health care provider? *

Yes
No

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