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Temple Beth Shalom Health Screening Form

If you are unvaccinated, a negative Covid test must be submitted within 72 hours of any indoor event.

  • Please complete this form for EACH PERSON of any age who will be in the building. 
  • All questions are required.

Have you or anyone living at home come into close contact with COVID-19 positive patients in the work place?

Have you or a household member, or any known close contact had a diagnosis of COVID-19 infection?

I agree that this acts as an electronic signature agreeing to the veracity of the information above and if the answer to any of these questions changes before the event, I will notify Temple Beth Shalom as soon as possible. Also, if the answer is yes to any of the previous questions, I understand I will not be entering the building.

By entering the property I acknowledge that there is an assumption of exposure to the Coronavirus (COVID-19) and any and all consequences that may result from such exposure, including but not limited to, physical injury, psychological injury, pain, suffering, illness, temporary or permanent disability, death or economic loss. This form is intended to notify the parties of the risks associated with visiting Temple Beth Shalom. By checking this box and submitting this form, I hereby acknowledge and assume such risks and/or potential consequences. I acknowledge receipt of this Coronavirus (COVID-19) Limitation of Liability Form and understand that the refusal to sign this form may result in the refusal to allow me to enter the premises.

If you are vaccinated, you don't need to do this again.
If uploading a test result, it must be within 72 hours of visiting Temple Beth Shalom.

If you are unable to upload the form, you can mail a copy of the form to 
Temple Beth Shalom
760 Route 6, Mahopac, NY 10541

or make an appointment with the office by calling (845) 628-6133


Thu, February 9 2023 18 Shevat 5783