I, the person named herein, knowingly, freely, and voluntarily consent to allow Berean to collect my body temperature, information about COVID-19 related symptoms and COVID-19 related personal contacts and travel exposure.

Berean Christian Church is committed to providing a safe environment for all who use our facilities. In an effort to reduce the risk of COVID-19 exposure on our premises, all members, volunteers, and guests who enter our facilities must complete this Self-Certification and Health Screening Form (Certification). This Certification requires that you perform the following:

A. A body temperature reading (must be less than 100.0 degrees Fahrenheit (“100.0 F”);

B. Certify that you do not have any COVID-19 related symptoms of illness; and

C. Certify that you have not experienced any COVID-19 related personal contact or travel exposure.

If you are unable or unwilling to complete this Certification, you will not be permitted to access our facilities. PLEASE NOTE: Individuals with confirmed or suspected COVID-19 diagnosis are not permitted to enter our facilities.

• Fever or Chills
• Cough
• Fatigue
• Nausea or vomiting
• Sore throat
• Headache
• Muscle or body aches
• Diarrhea
• Shortness of breath or difficulty breathing
• New loss of taste or smell
• Congestion or runny nose
• All other symptoms reported by CDC

1. In the past 14 days, I HAVE NOT had any member of my household, any person for whom I provide care, or any intimate partner been diagnosed with or believed to have COVID-19.

2. In the past 14 days, I HAVE NOT been within approximately 6 feet of a person confirmed or believed to have COVID-19 for a few minutes or more.

3. In the past 14 days, I HAVE NOT had direct contact with the bodily secretions of anyone diagnosed with or believed to have COVID-19 (e.g. being coughed on, touching used tissues with a bare hand, sharing food or drink, etc.).

4. In the past 14 days, I HAVE NOT traveled outside the state, excluding commuting from a home location outside of the state, and in particular internationally.{COVID-19: Self-Screening Certification:pdf:5f59ee7f62bef}

Acknowledgement: I understand that all information collected from me will be kept confidential. This Certification is not a medical diagnosis of COVID-19 and I am not being advised to consult a health care provider or to seek COVID-19 testing unless due to an emergency. My Certification results are solely to determine whether I may access the facility.

By using the submit button below, I hereby acknowledge and agree that I have executed this form by electronic signature, which shall be considered as an original signature for all purposes and shall have the same force and effect as an original signature. I understand and agree that I have a right to request and submit a paper copy of this form instead. I understand that I waive such right if I submit this form via electronic transmission. I also understand that I may receive a paper copy of my electronic submission upon my written request to bus.admin@bereanchristianchurch.org.