SGS Parent Consent for COVID-19 Testing

As required by New York State, SGS must begin the process of screening faculty, staff, and students in order to maintain in-person learning. The school is seeking your consent to test your child for COVID-19 infection.
If you consent, your child may receive a free diagnostic screening for the COVID-19 virus that will be administered by a trained medical professional.

SGS will use the Abbott BinaxNOW COVID-19 Ag Card screening tool, which will involve inserting a small swab, similar to a Q-Tip, into the front of the nose.  While reliable as a screening tool, these tests do not deliver 100% accurate results, and students who test positive will require follow-up testing using a more accurate instrument. You will be notified within 10 minutes if your child tests positive for COVID-19. Students who are positive for COVID-19 must follow all Erie County Department of Health criteria to return to school and will not be permitted to return to in-person learning.

The law requires and/or allows some information about your child to be shared with Erie County and New York State Public Health Agencies.  This includes notifying the Erie County Department of Health about the COVID-19 results of each student who is tested and may include the student’s name, date of birth, race, ethnicity, gender, address, phone number, and result of the COVID-19 test.

By signing below, I attest that:

• I have signed this form freely and voluntarily, and I am legally authorized to make decisions for the child named below.

• I authorize St. Gregory the Great School to test my child for COVID-19 infection.

• I understand that my child may be tested more than once during the 2020-2021 school year.

• I understand that this consent form will be valid through June 30, 2021, unless I revoke such consent in writing to Mrs. Julie Gajewski.

• I authorize my child’s test results and the other information listed above 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 move to distance learning and remain at home until he/she meets the criteria to return to school according to the Erie County Health Department.  
A student who tests positive will be referred to the Erie County Department of Health or New York State Department of Health for further testing.

• I understand that this screening 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 advice, care, and treatment for my child from his/her medical provider and that I will contact his/her medical provider if I have questions or concerns.

• I understand that, as with any medical test, there is the potential for a false positive or false negative COVID-19 test result.
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Student Last Name: *
Student First Name: *
Student Date of Birth: *
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Student Grade Level: *
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Electronic Signature: I understand and acknowledge that by checking this box, I am confirming that I have read this entire form and that the information I have provided is true and accurate. I intend for this to serve as my electronic signature and I am authorizing SGS to rely on my electronic signature. I understand and acknowledge that this electronic signature has the same legally binding effect as if I had placed my handwritten signature on a paper form. * *
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Parent/Guardian Last Name (i.e. person providing consent): *
Parent/Guardian First Name (i.e. person providing consent): *
Please provide the best phone number to reach you: *
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