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2022-2023 After School Registration
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Member Vaccination Status
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At this time, everyone entering must be fully vaccinated. Please complete a separate form for each person and include the date each person was fully vaccinated.
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First Name
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Last Name
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Email address
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Cell Phone number
Please complete a separate form for each person attending and include the date each person was fully vaccinated.
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Are you fully vaccinated?
Please Select One
Yes
No
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Date of your final vaccination
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Have you received a booster?
Please Select One
Yes
No
Date of your booster
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Do you have any signs of COVID-19 or have you been exposed to anyone with a confirmed case of COVID-19 in the last 10 days?
Please Select One
Yes
No
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Do you agree to notify Or Zarua if you become symptomatic or test positive for COVID within 5 days after attending services or any other event at Or Zarua?
Please Select One
Yes
No
By registering to attend, you acknowledge the significant risks associated with COVID-19 and that Or Zarua is making diligent efforts and taking reasonable precautions to mitigate those risks within its building. You understand that, despite its diligent efforts, Or Zarua cannot guarantee the health of anyone attending services or programs in its building.
Tue, February 7 2023 16 Shevat 5783