SFZC COVID-19 Safety Questionnaire

To help keep all participants of in-person SFZC events safe from COVID-19, we require that all teachers and attendees be fully vaccinated, and submit proof of vaccination. All fields are required, except as noted. If you have any questions or concerns please email using the contact information at the bottom of this form.

Which temple do you plan on visiting?

City Center TempleConference Center at City CenterGreen Gulch FarmOther

Event or group you will be attending or the name of the person with whom you will be meeting

Date of event or meeting

First Name

Last Name

Personal Email

Phone Number

Have you been vaccinated against Covid-19?

YesNo

What vaccine(s) did you receive? How many doses of each one have you received and what was the date of your last dose?

Please upload a copy of your CDC/National COVID-19 vaccination card or California Digital COVID-19 Vaccine Record/SMART Health Card here.

Do you have any symptoms of COVID-19?

YesNo

A coordinator will contact you for more information after you submit the form.

Have you had contact with anyone known to test positive with COVID-19 within 14 days of your visit?

YesNo

Have you tested positive for COVID within the last 10 days?

YesNo

If it has been more than 10 days since you tested positive for COVID, have you received a negative rapid antigen test since then?

YesNoNot applicable (have not had COVID)

A coordinator will contact you for more information after you submit the form.

Have you traveled outside the US within 14 days of coming to the temple? If so, which country or countries did you travel to?

If any of the following situations occur prior to visiting a San Francisco Zen Center temple, you are required to contact temple staff and may need to postpone your visit:

The onset of symptoms of COVID-19
Contact with anyone known to test positive with COVID-19 within 14 days of visiting the temple
International travel within 14 days of coming to the temple

I understand and agree

If you have any questions about this questionnaire or about your ability to visit any of our temples, please contact the Temple Coordinator at ellen.simpson@sfzc.org

If you have any questions about this questionnaire or about your ability to visit Green Gulch Farm please contact the Director's Assistant at ggfdirectorassist@sfzc.org