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COVID-19 Pre-screening
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Pre-screening Questionnaire

Pre-authorization is required for attendance at all in-person worship services. Though you may receive the initial clearance, on-site screening and a temperature check are still required. To help us prevent and slow the spread of COVID-19, please answer all questions as truthfully as possible.

Name

Phone

Email address

Date of registration:

Date of in-person worship service you plan to attend:

Have you had contact with someone who was diagnosed with COVID-19 (within the past 2 weeks)?

No

Yes

Within the last 2 weeks, have you experienced any of the following?

Abdomoinal Pain?

Yes

No

Bruising or bleeding?

Yes

No

Chills?

Yes

No

Conjunctivis?

Yes

No

Cough greater than 3 weeks?

Yes

No

Cough with blood?

Yes

No

Diarrhea?

Yes

No

Fever?

Yes

No

Headache?

Yes

No

Joint pain?

Yes

No

Muscle pain?

Yes

No

New loss of taste or smell?

Yes

No

Night sweats?

Yes

No

Rash?

Yes

No

Repeated shaking with chills?

Yes

No

Severe headache?

Yes

No

Shortness of breadth?

Yes

No

Sore Throat?

Yes

No

Unintentional Weight Loss?

Yes

No

Vomiting?

Yes

No

Weakness?

Yes

No

Will other individuals accompany you to this service?

Yes

No

If yes, how many?

If a visiting adult will accompany you to this church service or event, please direct them to the Ignite website for pre-authorization (if possible).

102 North St NW Leesburg, VA 20176 | | Tel: 703 651 - BURN