Detroit Unity Temple Covid-19 24- Hour Wellness Affidavit
RequiredRequired Question(s)
Please complete and print this affidavit for entry into our in-person services to adhere to the recommended covid-19 safety protocols. 
 
Required 1.

Do you have symptoms including fever, cough, and shortness of breath, sore throat, diarrhea or loss of sense, or taste?

Yes
No
Required 2.

Have you been in close contact (within 6 feet for more than 15 minutes without a face covering) in the last 14 days with someone with a diagnosis of COVID-19?

Yes
No
Required 3.

Have you or anyone in your household traveled internationally or domestically in the last 14 days?

Yes
No
Required 4.
I affirm the information I provided to be correct.

First Name:
Last Name:
Home Phone:



Date:                                                                                       


Signature:                                                                                                                       
 
To print form: right click then click print. Click the finish button below.
After you have printed the form, please sign and date it. 
Bring the completed affidavit with you to expedite your entry into the sanctuary.