Health Screening Questionnaire

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We are grateful that we can once again come together. However, due to the coronavirus, we require that you adhere to certain restrictions:

Non-vaccinated attendees are required to wear a mask over their mouth and nose the entire time they are in the building. This is not a personal decision; the mask is worn to protect others from infection, and non-compliance puts at risk everyone else at the minyan.

Everyone seated will be separated by at least three feet distance between chairs.

You may not attend if you have any of these conditions:

Cough - Shortness of breath or difficulty breathing
Chills - Repeated shaking with chills
Muscle pain
Headache
Sore throat
Loss of taste or smell
Diarrhea and fever
Feeling feverish or a measured temperature greater than or equal to 100.0 degrees Fahrenheit
Known close contact with a person who is lab confirmed to have COVID-19 or in contact with someone being tested for COVID -19 within 14 days from the last exposure.

Thank you.

* Which service(s) on what day(s) do you plan to attend? Please note: no children under age 12 at this time.

Where are you visiting from and how did you hear about FAS?

I would like to be added to the Fifth Avenue Synagogue email list.

* First Name

* Last Name

* Email

* Phone Number

Please Select OneI am fully vaccinated. (We define “fully vaccinated” as two weeks past complete vaccination).I am not fully vaccinated.

* I have answered the above vaccination question correctly and accurately, and understand the implications of offering an incorrect response.

I have answered the above vaccination question correctly and accurately, and understand the implications of offering an incorrect response.

* I waive, release and covenant not to assert against Fifth Avenue Synagogue or its agents, volunteers, or other representatives any claim relating to or arising out of COVID-19 or infection therefrom by reason of or in connection with my attendance at the Synagogue.

I waive, release and covenant not to assert against Fifth Avenue Synagogue or its agents, volunteers, or other representatives any claim relating to or arising out of COVID-19 or infection therefrom by reason of or in connection with my attendance at the Synagogue.

I do not currently have a fever above 100 degrees or unexplained symptoms such as loss of taste or smell, difficulty breathing, coughing, headaches or gastrointestinal difficulties.

I agree to wear a face mask at all times while inside the Synagogue building.

If I develop symptoms or find out I have been exposed to someone with Covid-19 I will let the Synagogue office know as soon as possible and will not attend services.

Tue, July 27 2021 18 Av 5781