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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 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 or attended outdoor 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
- Have you traveled to countries outside the United States, visited states with high levels of COVID, 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.
- Due state regulations parishioners answering yes to any of the above questions are asked not to attend our worship gathering.
- 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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