One -Time Consent for Test to Stay Sign Off

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Instructions:

Quarantine - Test to Stay
Students may participate in our “Test to Stay” program. If the parent agrees to participate in rapid testing on days 1, 3, 5, & 7, the student may attend in-person during the 14-day watch period. The BinaxNow test will be used for this monitoring program. Conscientious masking, negative test results every other day, and remaining symptom free will result in an unvaccinated close contact being able to stay in school during the 14 days. A signed waiver must be in place prior to testing. This form will serve as your agreement and consent.

Email *

POLICY

As a parent or legal guardian of a minor student (“Student”), I hereby authorize and give
my express consent to Bond County Community Unit #2 School District for my
child(ren) to be tested for Covid-19 in connection and authorization with the Bond
County Health Dept. I acknowledge that my child’s Covid-19 test results and associated
information will be shared with the Bond County Health Dept.

I understand that a nasal sample will be collected from the student(s) and tested for
Covid-19 using the Binax Now Covid-19 antigen test. If your child is tested at school,
you will be notified of the results. If a student receives a positive test result, you will be
contacted immediately to pick up the student from school and will be required to follow
the guidelines for isolation set by IDPH. The purpose of testing is to allow unvaccinated
and asymptomatic close contacts to remain in school as long as they test negative on
days 1,3,5,7. If any of these days fall on the weekend, the student will be tested on their
first day back to school. All testing will take place in each building's nurses office.
Testing will be administered by the district nurses. On occasion, the Bond County Health
Dept may assist district nurses with testing. I understand that BCCU#2 is not acting as a
student's medical provider and that this testing does not replace treatment by the
student's medical provider. I assume complete and full responsibility to take appropriate
action with regard to my child’s test results. I agree I will seek medical advice, care, and
treatment from the child's medical provider if I have questions or concerns, or if my
child’s condition worsens.

CONSENT

Release: To the fullest extent permitted by law, I hereby release, discharge and hold
harmless, the Bond County Community Unit #2 school district, including, without
limitation, any of its employees from any and all claims, liabilities, and damages, of
whatever kind of nature arising out of or in connection with any act or omission relating
to my child’s Covid-19 diagnostic test or the disclosure of my child’s Covid-19 test
results.

I acknowledge and agree that I have read, understand, and agree to the statements
contained in this form. This authorization is in effect for the entire 2021-2022 school
year, unless I revoke it in writing.

Student's Legal Name (as it appears in Skyward) *

Grade Level *

Student's School *

Student's Date of Birth *

YYYY

Parent/Guardian Name *

I hereby acknowledge that I have received a copy of this Authorization and Consent for COVID-19 of a minor child. I understand that I am consenting to the district's optional Test to Stay program. *

YES

If you are not available, can we leave a message with your child's emergency contact listed in Skyward? *

YES

A copy of your responses will be emailed to the address you provided.

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