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Church Contact -Form Fill

Section One
Q1

Date and Time

Month Day Year
Q2

Date and Time

Hour Minutes
Q3

Date and Time

AM/PM Option
Q4

Name

First Name
Q5

Name

Last Name
Q6

Age
Q7

Sex
Q8

Contact Number

Phone Number
Q9

Email
Q10

Address

Street Address
Q11

Address

Barangay
Q12

Address

City
Q13

Address

State / Province
Q14

Address

Postal / Zip Code
Q15

Temperature
Q16

Leader
Q17

Purpose of your visit?
Q18

Are you experiencing:
Q19

Have you worked together or stayed in the same close environment of a confirmed COVID-19 case?
Q20

Have you had any contact with anyone with fever, cough, cold, and sore throat in the past two (2) weeks?
Q21

Have you traveled outside of the Philippines in the last 14 days?
Q22

Have you travelled to any area in NCR aside from your home in the past 14 days?
Q23

If "YES," where?