Due to the 2019-2020 outbreak of the novel Coronavirus (COVID-19), New Psalmist Baptist Church is
taking extra precautions with the care of every member/visitor to include health history review and
enhanced sanitation/disinfecting procedures in compliance with CDC guidance.
Symptoms of COVID-19 include:
• Fever
• Fatigue
• Dry Cough
• Difficulty Breathing
I agree to the following:
• I understand the above symptoms and affirm that I, as well as all household
members, do not currently have, nor have experienced the symptoms listed above
within the last 14 days.
• I affirm that I, as well as all household members, have not been diagnosed with
COVID-19 within the past 30 days.
• I affirm that I, as well as all household members, have not knowingly been exposed
to anyone diagnosed with COVID-19 within the past 30 days.
• I affirm that I, as well as all household members, have not traveled outside of the
country or to any city considered to be a “hot spot” for COVID-19 infections within
the past 30-days.
• I understand that New Psalmist Baptist Church cannot be held liable for any exposure
to the COVID-19 virus caused by misinformation on this form or the health history
provided by each member/visitor..
Our church is following theses enhanced procedures to prevent the spread of COVID-19:
By signing below, I agree to each statement above and release New Psalmist Baptist Church from any
and all liability for unintentional exposure or harm due to COVID-19.
