Feast of Victory Lutheran Church

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Health Questionaire

Please complete this form for all in-church meetings.

Date *
Your Name: *
Phone Number (No Spaces, Please): *
Email *
Name of Meeting Leader: *

Health Screening And Contact Tracing

Your Temperature: *
Check all that apply to you in the last 14 days.
I live with someone who has COVID-19.
I have had close contact with someone who has COVID-19.
I have had no exposure to COVID-19.
In the last 14 days, have you traveled out of the greater Traverse City area?
*
YesNo
If Yes, where?
Have you recently started experiencing any of these symptoms? Please check only those that apply.
Fever or chills
Mild or moderate difficulty breathing
New or worsening cough
Sustained loss of smell, taste or appetite
Sore throat
Vomiting or diarrhea
None of these symptoms

Verification

Please enter any two digits *Example: 12
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Plan Your Visit

Complete this form to let us know you're coming, so we can have a host ready to welcome you and show you around!

First Name *

Last Name *

Email *

Phone Number *

Date of Visit *

Time of Visit *

Do you have children you would like to pre-register to save time when you arrive?
Yes

2+5=?