COVID-19 Response Form

If you have been affected by COVID-19, the coronavirus, we would like to be in prayer for you and help! Please fill out the information below so we know how to best serve you.

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* 1. Contact Information:

Name (First and Last):

Phone Number:

Email:

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* 2. How have you been affected by the Coronavirus?

Self-quarentined

Exposed to known case

Tested Positive

Other (please specify)

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* 3. What CrossWinds events did you attend in the last two weeks during the incubation period? Is there anyone we should contact who might have been affected? We will keep this anonymous unless you want to reach out to them directly. If not applicable please put N/A.

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* 4. On Prayer Request

Yes

Yes - Confidential Only

No - Staff Only

COVID-19 Response Form

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* 1. Contact Information:

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* 2. How have you been affected by the Coronavirus?

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* 3. What CrossWinds events did you attend in the last two weeks during the incubation period? Is there anyone we should contact who might have been affected? We will keep this anonymous unless you want to reach out to them directly. If not applicable please put N/A.

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* 4. On Prayer Request

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* 5. Ways we can help you:

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* 6. Campus