I plan to participate in the small group event identified above.  I understand that my Christian duty to protect the health and safety of the Herndon Church community requires me to disclose certain health information and observe certain rules as a condition of my participation during the current COVID-19 pandemic.   

1. Health Information

     a. I acknowledge and promise that I have not had two or more of the following symptoms of COVID-19 within 14 days prior to the event: fever, shortness of breath or difficulty breathing, chills, persistent cough, flu-like symptoms, diarrhea or intestinal upset, fatigue, sore throat, headache, muscle pain, or recent loss of taste or smell. 

     b. I have not been in contact with anyone experiencing symptoms of COVID-19 within the past 14 days or who has tested positive for COVID-19 within the past 14 days.
     
     c. I have not tested positive for COVID-19 or, if I have tested positive, I experienced none of the symptoms (described in #1a above) for 14 days after I tested positive.  Also, I am not awaiting COVID-19 test results.

     d. If I develop two or more of the symptoms described in #1a above, I will immediately notify a pastor of Herndon UMC, will avoid contact with others, and will seek medical attention.  (The pastors will disclose and use any information in accordance with the law and public health guidance.)

2. Restrictions on Small Group Gatherings

     a. I will wear a mask at all times.

     b. I will maintain a social distance of six feet from other persons at all times.

     c. I will bring my own seating.

     d. I will not bring any food or drink to share.  (I may take off my mask only while drinking from a personal container.) 

     e. I will not share any bulletins, written materials, or any other items.

     f. I understand that the Herndon UMC building will be closed and restroom facilities and hand wash stations will not be available.

     g. I understand that attendance for meetings is limited to 12 people and I may not bring a guest to a meeting.  (This does not apply to worship.)

     h. I understand the event may not last longer than 60 minutes and I may not linger on Church grounds, including the parking lot, after the conclusion of the event.

     i. I understand that if I, or any other participant, does not comply with these rules, then the gathering will be terminated immediately.

By my signature below, I acknowledge that the information above is true and correct and that I will comply with the rules recited above.  Furthermore, I recognize that I will need to complete a new acknowledgement form for each small group event I participate in.

If the participant is a minor, then this form must be signed by a parent or guardian.