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Register2020-11-10T08:45:41+00:00

Name
Surname
Physical Address
Street Address
Phone Number
Email
Who will be attending the service?
- Only Me
- My Family
- My Friend
How many extra family members will attend?*
This does not include yourself.
My Friend - Name
My Friend - Surname
My Friend - Phone Number
My Friend - Email
My Friend's - Physical Address
Street Address
Family Member 1 - Name
Family Member 1 - Surname
Family Member 1 - Phone Number
Family Member 1 - Email
Family Member 2 - Name
Family Member 2 - Surname
Family Member 2 - Phone Number
Family Member 2 - Email
Family Member 3 - Name
Family Member 3 - Surname
Family Member 3 - Phone Number
Family Member 3 - Email
Family Member 4 - Name
Family Member 4 - Surname
Family Member 4 - Phone Number
Family Member 4 - Email
Family Member 5 - Name
Family Member 5 - Surname
Family Member 5 - Phone Number
Family Member 5 - Email
Do you have a fever?*
- Yes
- No
Recent coughing or sneezing?*
- Yes
- No
Sore throat?*
- Yes
- No
Difficulty breathing?*
- Yes
- No
Loss of smell or taste?*
- Yes
- No
Have you been in contact with someone recently that tested positive for Covid-19?*
- Yes
- No