This consent provides Prospect Heights School District No. 23, with your permission, to perform a SHIELD Saliva Test (collectively known as “Test”) as part of our COVID-19 Safety Protocols. The purpose of providing the Test is based on the District’s need to maintain a safe environment for employees and students, and other essential persons with whom you may have come into contact.

In consideration for receiving the opportunity to participate in COVID-19 testing (hereinafter “Testing”), which is provided by Prospect Heights School District No. 23, I hereby release, waive, discharge, covenant not to sue, and agree to hold harmless for any and all purposes District 23 and their healthcare staff, other staff members, administrators, board members, servants, agents, volunteers, and/or any other employees (herein referred to as “Indemnitees”) from any and all liabilities, claims, demands, injuries (including death), or damages, including court costs and attorney’s fees and expenses, that may be sustained by me or my child while participating in Testing, traveling to and from the Testing, and/or on the premises owned or leased by Indemnitees while Testing.

I am fully aware that the Testing provided by the District 23 may involve COVID-19 tests that have not gone through a full FDA approval process and instead obtained emergency use authorization (EUA) or registered and are pending such processing and that the results could produce false positives or false negatives, or be administered in a way that otherwise produces inaccurate results. I am also fully aware that the organization is not providing medical care or giving a medical diagnosis with Testing and that I or I, on behalf of my student, should consult my doctor or go to an emergency room if I have any questions, serious symptoms, and/or to obtain medical advice from my own doctor as to the results of the Testing.

Your student(s) is/are eligible for a District paid and provided Test. The outcome of the Test will be provided to you by the District Testing Medical Professional or designee. If the test is negative, the District Testing Medical Professional will provide next steps in accordance with IDPH/Cook County Health Department Exclusion Procedures and Protocols. In the event the Test is positive, the District Testing Medical Professional or designee will contact you with next additional steps, including exclusion and a strong recommendation to contact your doctor to discuss the test results.

By signing below, I :

* hereby waive my student’s rights regarding protected health information under HIPAA, FERPA, and/or ISSRA, to the extent necessary to complete the testing and to allow District 23 to provide the results (whether positive or negative) of  the Test to the organization which has arranged for the Test, and local and state public health authorities (which may result in further direct communication from those entities to me for further follow-up and contact tracing). Protected health information will not be reused or disclosed by the organization to any person or entity other than above, except as required by law.

* voluntarily acknowledge that you have the right to consult with your Doctor prior to testing of your student(s);

* voluntarily acknowledge that you have been provided an opportunity to ask questions before proceeding with a COVID-19 Test;

* voluntarily acknowledge that you understand that if you do not wish to continue with the Test that you may decline and not test, but that if you do not test you and your student(s) will abide by the IDPH/Cook County Health Department Exclusion Procedures and Protocols;

* voluntarily consent to this Test for the purpose of determining whether your student(s) has/have COVID-19;

* voluntarily consent to the disclosure of Test results to the District Testing Medical Professional which will be maintained as a medical record in the same manner that the District currently maintains other medical records such as immunizations and physicals;

* voluntarily agree to cooperate with the District in any contract tracing procedures, if applicable; and

* voluntarily agree to hereby release, discharge, and hold harmless, the Board, its members, employees, agents, officials, officers, insurers and/or attorneys, from any and all claims, liability, and damages, of whatever kind or nature, arising out of or in connection with any act or omission relating to my student(s) Test or the disclosure of the Test Results in accordance with the IDPH and/or law.