Screening Questionnaire / Booking Form for Members and Visitors

The health and well-being of our congregation, visitors, employees, and communities remain our primary priority and as such we are now requiring all visitors to provide responses to the below questions prior to being permitted entry into our facilities. We apologise for any inconvenience caused.

 

Please Note
If you have completed this form before, please fill in your cellphone number to call up your information.

Cellphone Number  
  

 

Current Bookings:
27 Jun 08h30
10h30
18h30		 57
50
53
04 Jul 08h30
10h30
18h30		 52
31
43
11 Jul 08h30
10h30
18h30		 39
11
16
18 Jul 08h30
10h30
18h30		 11
1
12
"Doping met die Heilige Gees" Service:
 08 Jul		 18h30 36
Bybelskool:
 29 Jun		   23

 

Name * Surname *
ID Number * Cell Number *
Address *    
Which service will you be attending? *
08h30   10h30   18h30  

Bybelskool

 Date of Service: * Format: YYYY-MM-DD
1. Do you experience any of the following flu-like symptoms:

* fever
* cough / scratchy throat
* loss of smell / taste
* trouble breathing / shortness of breath		 Yes     No
2. Do you have heart, lung, kidney disease or diabetes? Yes     No
3. Have you been in contact with a confirmed Covid-19 person? Yes     No
4. Have you traveled in the past 14 days to a Covid-19 region? Yes     No
I hereby agree that the church assumes no liability / responsibility for any harm or illness as a result of visiting the church property. I declare that the information provided above is accurate.
Date *:
* denotes a required field