Everyone MUST fill out this form to participate in the act of Sunday worship. Please help young
children or anyone who needs help with handwriting. Bring this form to a Screener to take
your temperature. We use an infrared thermometer.
Body Temperature ____________________
Name ______________________ Date _______________ Time ___________
Contact Info: Tel # ______________________________________ (cell) (home)
Email address: ____________________________________________________
Home mailing address: ______________________________________________
_________________________________________________________________
Please answer following questions.
If you answer “Yes” to any of these questions below the screener
may notify the lead usher and politely ask you to leave the building immediately.
Please understand. It is for protection for all including you. Thank you very much for your help.
Do you have:
1. Fever (> 100 F) within past 24 hours? Yes No
2. Coughing/Sneezing? Yes No
3. Sore Throat? Yes No
4. Shortness of breath? Yes No
And/or the following within the past 14 days?
1. Recent Travel to high risk areas? Yes No
2. Exposure to someone with documented or suspected COVID-19? Yes No
3. Have you and those in your household practiced
self-quarantine as directed by local government? Yes No
4. 4. Have you visited any area that is considered a hotspot? Yes No
By signing this questionnaire I understand:
• I have provided all the information with the best knowledge on my health condition.
• The church is NOT responsible for the COVID-19 infection after my participation in the act of
worship today. We will keep you in prayer for your health.
• I will corporate the directions of pastor, ushers and liturgical ministers during my stay in the building.
Signature __________________________________________________
Good Shepherd United Methodist Church
Silver Spring, MD
