Your Safe Pass | Agape House

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(609) 759-0243

Covid-19 Health Declaration

How are you feeling today? (All participants need to fill out this survey at every in-person meeting at Agape House)

First Name

Last Name

Email

Phone (only for emergency or contact tracing)

My body temperature is lower than 98.6°F/ 37.5°C

I am not experiencing the symptoms: fever, cough, sore throat

I haven’t been in close contact with a Covid-19 patient in the last 14 days

I have NOT traveled in the past 14 days to any regions affected by COVID-19 (international OR domestic)?

Event Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

Contact

(609) 759-0243

©2018 by Agape House

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