COVID-19 Screening Check-In : Ephesus Seventh-day Adventist® Church Agincourt ON

If you prefer a paper copy, please download, print and complete this form and bring it with you on your visit. A copy of the form can be found here: COVID-19 Screening Paper Copy

Your Information

Please use this form on the day you plan on visiting or entering the church premises. Each person in your family is required to fill out and submit an individual form.

Date of Visit

Full Name

Contact Phone Number

Contact Email

Screening Questions

If you answer "Yes" to any of these questions or have checked off any of the symptoms listed, please stay home and self-isolate immediately. Call TELEHEALTH (1-866-797-0000) or your health care provider to find out if you need to be tested for COVID-19.

Do you have any of the following symptoms:

Fever, Cough, Runny Nose or Sore Throat
Trouble Swallowing or Difficulty Breathing
Loss of Taste or Smell
Nausea, Vomiting or Diarrhea
None of the above

Have you traveled outside of Canada in the past 14 days?

Have you been in close contact with someone who is sick or has confirmed COVID-19 in the past 14 days?

Confirmation and Acknowledgement

I understand this questionnaire and have answered the questions truthfully and voluntarily. I further understand this information is only collected for the purpose of contact tracing by Toronto Public Health and will not be shared for any other purpose or with any other organization unless required for contact tracing. By selecting "Yes", you are acknowledging this statement prior to entering the premises of the church.

Ephesus Seventh-day Adventist^® Church