Consent for COVID-19 Diagnostic Testing:

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

I hereby consent to COVID-19 diagnostic testing of my student(s) including the collection, testing, and analysis, of a sample specimen(s) by Harlem Consolidated School District 122 (the “District”), or an appropriate representative(s) of the District, including but not limited to SHIELD IL. I acknowledge and understand that this testing of my child will require the collection of a sample specimen(s) which may be obtained by saliva from trained personnel. I understand that there are risks—including, but not limited to, the potential for false positive or false negative test results—and benefits—including, but not limited to, helping to maintain a safe school environment—associated with my student undergoing a diagnostic test for COVID-19. I assume full responsibility for taking appropriate action with regards to my student’s test results. Should I have questions or concerns regarding my student’s results, confirmation of the test results, or a worsening of my student’s condition, I shall promptly seek advice and treatment from an appropriate health care provider.

Email *

Terms and Conditions:

Notice of Student Privacy Rights and Practices: All results obtained through the District’s testing protocol shall be used for COVID-19 mitigation, tracking, and other purposes which may include surveys and data collection by the Illinois State Board of Education. All such results shall be retained in a confidential manner consistent with applicable State and Federal law and regulation.

Attestation:

I attest that I have authority to execute this form providing consent for my student to participate in this COVID-19 diagnostic testing protocol.

Voluntary Participation:

I understand that my student’s participation in this COVID-19 diagnostic testing protocol is voluntary. I understand that my student may continue to attend school if I do not consent to their participation in this testing protocol or withdraw my consent, except for any required school exclusion due to an isolation/quarantine period consistent with local public health department, IDPH or CDC guidance.

Disclosure of Test Results and Associated Information:

I acknowledge that the District may disclose my student’s COVID-19 test results and mine/my student’s associated information to appropriate representatives of the District and/or appropriate Federal, State, county, or other governmental and regulatory entities as may be permitted by law. Due to the ongoing public health crisis, this may include sharing my/my child’s test results and associated information with public health authorities. I understand that the District and/or the third-party vendor all will notify me of my child’s positive test results via email and phone call. I understand that the District will provide me with information on my child’s test results and quarantine procedures.

Release:

As consideration for this testing, I hereby, for myself, and for my heirs, executors, administrators and assigns, waive, release and forever discharge the District, its Board members individually, administrators, officers, employees, volunteers, agents and representatives from any and all manner of action and actions, cause and causes of action, suits, debts, accounts, damages, claims and demands whatsoever in law, or in equity, which I may now have or may acquire, by reason of personal injury or death or loss of or damage to personal property or any other reasons, which may be related in any way to the COVID-19 testing provided by the District or SHIELD IL which may accrue on account of my child’s participation. I acknowledge and agree that I have read, understand, and agreed to the statements contained within this form. I have been informed about the purpose of the COVID-19 test being used, the procedures to be performed, the potential risks and benefits, and any associated costs. I have been provided an opportunity to ask questions before providing my consent to COVID-19 testing and I understand that I may withdraw my consent to COVID-19 testing at any time. I have read the contents of this form in its entirety and I voluntarily consent to testing for COVID-19.

Indemnification:

I hereby agree to indemnify, defend, and hold harmless the District, its Board members individually, administrators, officers, employees, volunteers and agents from any and all claims of responsibility or liability for personal injury, property damage, or loss which may arise from or is in any way connected with the COVID-19 testing provided by the District or SHIELD IL on account of my child’s participation.

Effect of Consent:

By signing below, I am indicating that I voluntarily consent to and authorize the diagnostic testing described above for the detection of COVID-19. This consent is ongoing for the duration of the District’s implementation of a diagnostic testing protocol and I acknowledge that it may be revoked at any time in writing.

The tests used by the District have been approved for diagnostic use through Emergency Use Authorization by the Food and Drug Administration (“FDA”). However, a rapid test alone may not be sufficient to detect or rule out the possibility that an individual has been exposed to or is infected with COVID-19. Individuals who receive a test should carefully monitor their own symptoms.

Student's Last Name *

Student's First Name *

Student's Middle Name

Student's Date of Birth *

YYYY

The student ID number is six digits. This can be found when you log into skyward family access under "Student Information". *

School Student Attends *

Harlem High School

Harlem Middle School

I give consent for my student to participate in the weekly testing offered through SHIELD Il: *

I give consent for weekly testing through SHIELD IL PCR saliva test and the option to participate to test-to-stay program.

Required

Signature Acknowledgement

The electronic signature below and its related fields are treated by Harlem Consolidated School District 122 as a physical handwritten signature on a paper form.

By submitting this form I verify that all the information provided is true and correct to the best of my knowledge.

Electronic Signature (Parent/Guardian Full Name) *

Parent/Guardian Email Address *

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Harlem Consolidated School District #122. Report Abuse

Forms