Health Certification Form for Employees, Congregants and Visitors - Form - Scarsdale Synagogue Temples Tremont and Emanu-El

First Name

Last Name

Email Address

* Contact Phone Number

I would like to enter the Scarsdale Synagogue Temples Tremont and Emanu-El building. I understand that, in light of the COVID-19 pandemic, Scarsdale Synagogue will not allow any employee, congregant or visitor, including me, to enter the building if such employee, congregant or visitor answers “YES” to any of the following statements. I also recognize that any employee, congregant or visitor, including me, will be denied entry if the Scarsdale Synagogue staff or its clergy reasonably believe that I am experiencing symptoms of COVID-19.

I hereby certify that I am accurately answering all of the following statements:

* I have tested positive for COVID-19 (and I have not met CDC guidelines to end my isolation), and/or I have been advised by a health care provider to assume I have COVID-19.

Please Select OneYesNo

* I have had symptoms of COVID-19 during the last 14 days (e.g., fever of 100 degrees Fahrenheit or higher, fever-like symptoms such as chills or sweating, new cough, new shortness of breath or wheezing, new absence of taste or smell, headache, diarrhea, sore throat, muscle aches, abdominal pain or general malaise).

Please Select OneYesNo

* To my knowledge, I have come into close physical contact with someone (within 6 feet of the person, for over 1 minute) who has either tested positive for COVID-19 within the last 14 days, or has shown symptoms of COVID-19 within the last 14 days, and/or has been advised by a health care provider to assume they have COVID-19.

Please Select OneYesNo

* Within the last 14 days, I have travelled out of New York State to any of the states or countries deemed high-risk for COVID-19 by either the NY State or Federal governments

Please Select OneYesNo

I have been advised and I understand that Scarsdale Synagogue cannot guarantee a completely COVID-19 free environment and that, if I consider myself to be high-risk for COVID-19, I should not enter the Scarsdale Synagogue building. By signing below I acknowledge and agree that, to the maximum extent permitted by law, Scarsdale Synagogue shall have no liability if I am exposed to or contract COVID-19 as a result of my presence in the Scasdale Synagogue building.

* Today's Date

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* By typing my name here, it serves as my signature

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