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- Return to Mass

COVID-19 Questionnaire and Release of Liability
The maximum number of form submissions has been reached. This form is currently not available.
- Each person planning to attend Mass at STA you must complete a COVID-19 Protocol Questionaire below prior to arrival (this includes children and infants). Once you have completed the liability waiver you will receive a confirmation that your form has been received.
  
  Parishioners who are particularly vulnerable (e.g., over the age of 60, those who have been medically diagnosed with heart or lung conditions, diabetes, or who are immune-compromised), and those who are ill or suspect they may be ill, should remain at home. Livestreaming of our Sunday Mass on our YouTube and Facebook Live channels will continue, with Mass at 9:30am.
- Please review and affirm acceptance of the STA guidelines and waiver liability.
  
  **In order to attend I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing**
  
  I further acknowledge that St. Teresa of Avila Catholic Church has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19.
  
  I further acknowledge that St. Teresa of Avila Catholic Church cannot guarantee that I will not become infected with the Coronavirus/COVID-19.
  
  I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, parish staff, and other parishioners and their families.
  
  I voluntarily seek to attend public Mass at St. Teresa of Avila Catholic Church and acknowledge that I am increasing my risk to exposure to the Coronavirus/COVID-19.
  
  I acknowledge that I must comply with all set procedures and guidelines to reduce the spread while attending Mass.
  
  I attest that:
  I am not experiencing any symptom of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell.
  
  I do not believe I have been exposed to someone with a suspected and/or confirmed case of the Coronavirus/COVID-19.
  
  I have not been diagnosed with Coronavirus/COVID-19 and not yet cleared as non-contagious by state or local public health authorities.
  
  I am following all CDC recommended guidelines as much as possible and limiting my exposure to the Coronavirus/COVID-19.
  
  **I hereby release and agree to hold St. Teresa of Avila Catholic Church and the Archdiocese of Washington, DC harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of the church, or that may otherwise arise in any way in connection with any public Mass services or events while attending St. Teresa of Avila. I understand that this release discharges St. Teresa of Avila Catholic Church and the Archdiocese of Washington, DC from any liability or claim that I, my heirs, or any personal representatives may have against the church with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to participating in and attending any Mass services and events held at St. Teresa of Avila Catholic Church. This liability waiver and release extends to the Church and Archdiocese of Washington, DC together with the Archbishop, Priests, Deacons, and employees**
  I Agree Please select this field.
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Age REQUIRED Please fill out this field. Please enter an integer (number).
- Address REQUIRED Please fill out this field. Please enter valid data.
- City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
- Email REQUIRED Please fill out this field. Please enter an email address.
- Please confirm which Mass you wish to attend REQUIRED Please fill out this field.
- Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- Have you been fully vaccinated with the COVID-19 vaccine? REQUIRED Please fill out this field.
- Today’s Date REQUIRED Please fill out this field. Please enter a date.
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