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Parent Consent for Rapid COVID-19 Antigen Test

Required

Student 1required
First Name
Last Name
Must contain a date in M/D/YYYY format
SchoolrequiredPlease select up to 1 choice
Please select up to 1 choice
Student 2required
First Name
Last Name
Must contain a date in M/D/YYYY format
SchoolrequiredPlease select up to 1 choice
Please select up to 1 choice
Student 3required
First Name
Last Name
Must contain a date in M/D/YYYY format
SchoolrequiredPlease select up to 1 choice
Please select up to 1 choice
Student 4required
First Name
Last Name
Must contain a date in M/D/YYYY format
SchoolrequiredPlease select up to 1 choice
Please select up to 1 choice
Student 5required
First Name
Last Name
Must contain a date in M/D/YYYY format
SchoolrequiredPlease select up to 1 choice
Please select up to 1 choice
Student 6required
First Name
Last Name
Must contain a date in M/D/YYYY format
SchoolrequiredPlease select up to 1 choice
Please select up to 1 choice

Please carefully read the following informed consent, which is applicable to preschool thru 17-year-old students:

  1. I understand that the COVID-19 testing will be conducted through a BinaxNOW antigen test or another acceptable test as made available to my child’s school by the MDHHS.
  2. I understand that the ability to receive testing is limited to the availability of test supplies.
  3. I understand that I will be notified if my child receives a positive test result at school.
  4. I understand that testing does not replace treatment by a medical provider. I assume complete and full responsibility to take appropriate action with regard to my child’s test results and medical care. I will seek medical advice, care, and treatment for my child from a medical provider or other health care entity if I have questions or concerns, if my child develops symptoms of COVID-19, or if my child’s condition worsens.
  5. I understand it is my responsibility to inform my child’s healthcare provider of a positive test result, and that a copy will not be sent to the healthcare provider for me.
  6. I understand that the antigen test result will be available in 15-30 minutes. If the result is positive, I may elect to confirm the results with a PCR test as available through my child’s health care provider.
  7. I understand and acknowledge that a positive antigen test result is an indication that my child needs to self-isolate to avoid infecting others until the specified isolation period is completed.
  8. I understand that a positive test result will be disclosed to the appropriate public health authorities as indicated by public health code requirements.
  9. I understand that I may withdraw my consent for my child to participate in testing at school at any time by contacting my child’s school office.
CONSENT TO TEST FOR COVID-19
Parent/Gaurdian Namerequired
First Name
Last Name