COVID Screening For In-Person Volunteers

First Name

Last Name

Phone

Date of On-Site Service

Program You Are Volunteering With

Group Name (if applicable)

Are you currently experiencing, or have you experienced in the past 14 days, any of the following symptoms?

Fever (100.4 or greater)
Chills
New cough
Shortness of breath
Sore throat
Muscle aches
New headache
Loss of taste or smell
Diarrhea, nausea, or vomiting
Have you been exposed to, or in the proximity of anyone, that is known to have tested positive for COVID-19, or anyone who is waiting on COVID-19 results?

I have not experienced any of the above symptoms. I acknowledge and understand that there may be active COVID-19 positive cases onsite at Community First! Village during my service and am personally assuming the inherent risk of participating in service at Community First! Village.

I Agree

Date of Signature

The information collected on this form will be used to determine only whether you may be infected with COVID-19. The information on this form will be maintained as confidential.

Contact Information

We empower communities into a lifestyle of service with the homeless.

6,219,400

MEALS SERVED to the homeless in Central Texas through MLF’s food truck ministry.

13,741

HOURS SERVED in 2021 by dedicated volunteers in Community First! Village.

SUPPORT OUR MISSION

325

FORMERLY HOMELESS NEIGHBORS now living at home in Community First! Village.