Family Declaration

Family Health Declaration Form

We are blessed to be able to gather again for worship. Please help us by completing this form.

* Indicates required field

Family Name *

Total number attending *

First name(s) of each family member attending *

Primary Mobile Phone Number *

Primary Email *

I am or someone in my family is under work-related medical surveillance. *

Yes No

(Either way, you are welcome to attend, we just need to be aware for seating arrangement purposes.)

In the past 14 days I have or someone in my family has travelled outside of Hong Kong. (Beyond travel connected to medical surveillance listed above.) *

Yes No

In the past 14 days I have or someone in my family has had close contact with or cared for someone diagnosed with COVID-19. *

Yes No

In the last 14 days I have or someone in my family has experienced some cold or flu-like symptoms including fever, cough, sore throat, respiratory illness, difficulty breathing. *

Yes No

I declare that all the information given above is true and correct.

Agreed

To be compliant with the Personal Data (Privacy) Ordinance, data provided by you will be filed as an internal record. Personal data will never be revealed to a third party without your consent.

Family Health Declaration Form

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