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COVID

- Church
Contact Us
- Office
  
  518-785-1351
  salathamrcda.org

The maximum number of form submissions has been reached. This form is currently not available.
- In an effort to reduce the risk of COVID-19 exposure to St. Ambrose fellow Parishioners, all participants requesting to receive Holy Communion must complete the following screening questions:
- Date REQUIRED Please fill out this field. Please enter a date.
- I agree that I participated via live stream Mass
  I Agree Please select this field.
- First name of person completing this form REQUIRED Please fill out this field. Please enter valid data.
- Last name of person completing this form REQUIRED Please fill out this field. Please enter valid data.
- Email REQUIRED Please fill out this field. Please enter an email address.
- Phone Number REQUIRED Please fill out this field. Please enter a phone number.
- Please list all members of your family receiving Eucharist REQUIRED Please fill out this field.
- Have you traveled to countries outside the United States, visited states with high levels of COVID, New York City and/or Westchester County or been in close contact with anyone who has traveled to those areas within the last 14 days? REQUIRED Yes No Please fill out this field.
- If yes, please list the location below
- Have you had close contact with or cared for someone diagnosed with COVID-19 within the last 14 days? REQUIRED Yes No Please fill out this field.
- Have you experienced any cold or flu-like symptoms in the last 14 days (fever, cough, shortness of breath or other respiratory problem)? REQUIRED Yes No Please fill out this field.
- Parishioners answering yes to any of the above questions will not be permitted to receive Holy Eucharist.
- By checking this box, I acknowledge, that all information is accurate and completed by me, person named above. REQUIRED Yes Please fill out this field.
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