FAITH CHRISTIAN ASSEMBLY

20 Wayne Avenue, West Haverstraw, NY 10993

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Health Declaration

Please fill out the following health declaration form in order to participate in our activity. Submissions are valid up to 48 hours prior to attending services.

First Name

Last Name

Email

My body temperature is lower than 98.6°F/ 37.5°C

Have you been in contact with anyone who has tested potive for Covid-19 or Are you experiencing any flu symptoms ?

No

Yes

Date

Initials

I confirm that the information given in this form is true

Thanks for submitting!

"Loving God, Loving People, Living By Faith"

20 Wayne Avenue, West Haverstraw, NY 10993

Rockland County, NY

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