Student Consent for COVID-19 Rapid Test
Dear HCSD Families,

The Governor's Micro-Cluster Action Initiative and the New York State Department of Health (NYSDOH) requires schools providing in-person instruction to test specific percentages of in-person students, teachers, and staff for COVID-19 if the school is in a designated yellow, orange, or red zone, in order to continue in-person learning. Students who are learning 100% virtually do not need to fill out this form.

The Hudson City School District (the “District”) is seeking your consent to test your child for COVID-19 infection.  If you consent, your child may receive a free diagnostic test for the COVID-19 virus that will be administered by a certified or licensed medical provider (LPN, or RN). A rapid COVID-19 test (BinaxNow Antigen Test) will be used, which will involve inserting a small swab, similar to a Q-Tip, approximately one inch into the front of the nose.  Please note that these tests are non-invasive and are not the deep-swab procedures performed at medical facilities. We will notify you prior to the administration of the test if your child is randomly selected AND you will be notified if your child tests positive for COVID-19. Any students who test positive will be immediately sent home and must be kept at home until meeting Columbia County Department of Health quarantine criteria to return to school. Please contact your child’s doctor immediately to review the test results should your child test positive for COVID-19.  
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Email *
Student First Name (please use their full name as listed in the Parent Portal, not a nickname) *
Student Last Name *
Student Date of Birth *
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School Student Attends *
**Please read the following carefully and respond 'yes' or 'no' for your consent below.**   Testing Consent: The law requires and/or allows some information about your child to be shared with Columbia County and New York State Departments of Health agencies. This includes notifying the Columbia County Department of Health about the COVID-19 results of each student who is tested, including the student’s name, date of birth, race, ethnicity, gender, address, phone number, and result of the COVID-19 test. By digitally signing below, I attest to the following: I have signed this form freely and voluntarily, and I am legally authorized to make decisions for the child named above. I authorize the Hudson City School District to test my child for the COVID-19 infection. I understand that my child may be tested multiple times over the 2020-21 school year.  I understand that this consent will be valid through June 30, 2021, unless I revoke such consent in writing. I authorize my child’s test results and other information to be disclosed to any governmental entity as may be required or permitted by law. I acknowledge that a positive test result will require my child to be sent home from school and remain home until they meet the criteria to return to school according to the Columbia County Department of Health. I understand that this testing does not replace treatment by my child’s medical provider, and I assume complete and full responsibility to take appropriate action regarding my child’s test results. I agree that I will seek medical care, advice and treatment for my child from their medical provider if I have questions or concerns. I understand that, as with any medical test, there is a potential for a false positive or a false negative COVID-19 test result.   *
Name of Parent/Guardian providing/not providing consent *
Optional: Reason for not providing consent if you responded no.
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