Health Screening - Trinity Church Wall Street

Language:

Health Screening

Welcome to Trinity Church. Before entering the church property, please fill out the form below for health screening and contact tracing. By submitting this form, you acknowledge that you may be contacted either by phone call or SMS text for contact tracing purposes. Please note that submitting this form does not guarantee a seat at Trinity Church, St. Paul's Chapel, or Trinity Commons as capacity is limited at this time.

First Name

Last Name

Number of Guests (including yourself)

Additional Guests (same household only - First Name, Last Name if different)

Phone Number

In the past 10 days have you experienced any of the following new or worsening symptoms?
• Fever, fatigue, shortness of breath, or difficulty breathing
• Sinus congestion, runny nose, sore throat, muscle or body aches
• Loss of taste or smell, headache, loss of appetite or gastrointestinal discomfort
• Persistent cough

No Yes

Have you been fully vaccinated? ( Fully vaccinated means two weeks post second injection of Pfizer or Moderna vaccines, or first injection of Johnson & Johnson vaccine. )
Yes No