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This form applies to everyone in a family unit. If any member is experiencing symptoms or under quarantine, the rest of the family cannot attend. Please disregard any information not part of this form.

* First Name

* Last Name

* Email

* Phone Number

* I wish to attend October Birthday Shabbat!

Friday, October 15

Total number of people attending

* Have you had any of the following symptoms (check all that apply):

Fever above 100Unusual TirednessNew Onset of CoughAches & PainsSore ThroatDiarrheaLoss of taste or smellNone of the above

* I attest that everyone over the age of 18 in my family that has received the COVID-19 vaccine, either the Johnson & Johnson one dose or the Moderna/Pfizer two dose vaccine.

I attest that everyone over the age of 18 in my family that has received the COVID-19 vaccine, either the Johnson & Johnson one dose or the Moderna/Pfizer two dose vaccine.

* If I had any of these symptoms, I attest (both are required for entry):

I have quarantined for at least 10 days from the start of symptoms.It has been at least 3 days since the symptoms completely resolved.Not Applicable

* I attest that I have NOT had direct contact with anyone known COVID-19 unless I was appropriately using personal protective equipment (PPE).

I attest that I have NOT had direct contact with anyone known COVID-19 unless I was appropriately using personal protective equipment (PPE).

* I have NOT tested POSITIVE to any COVID-19 test within the past 10 days.

I have NOT tested POSITIVE to any COVID-19 test within the past 10 days.

* I understand that by reserving a space that I am agreeing to follow the guidelines and restrictions that Congregation Ner Tamid's Covid-19 Task Force is requiring.

I understand that by reserving a space that I am agreeing to follow the guidelines and restrictions that Congregation Ner Tamid's Covid-19 Task Force is requiring.

Thu, April 25 2024 17 Nisan 5784

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