Elaine Ellis- Patient Demographics Form-COVID-19 Testing- January 2021

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Elaine Ellis Center of Health (EECH) will be providing COVID-19 testing at IDEA PUBLIC CHARTER SCHOOL for staff and IDEA families. If you wish to participate, please complete the following information. *One Google form per person.

Email *

Full Name *

How are you connected to IDEA PCS?

IDEA Student/Family Member

IDEA Staff Member/Family Member

Date of Birth *

YYYY

Address *

Telephone Number *

Gender *

Female

Male

Race *

I am registering for the following COVID Testing Date (check all that apply) *

COVID-19 Testing- Thursday, January 28th 9:30 am- 10:30 am @ IDEA

Required

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