La Grange ISD Student Consent Form
Complete this Form to participate in Optional Student Covid-19 Testing 2020-2021.

For a blank copy of the form to print out, sign, and return; please see the La Grange ISD Covid-19 Website.

Items marked with an * are required to complete the form
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To be completed by parent, guardian, or adult student (18 yrs +)
You will be notified with test results either via cell phone, email, or both.
Parent/Guardian Name *
Parent/Guardian Cell Phone Number (Parent will be contacted via phone call prior to student being tested) *
Parent/Guardian Email Address *
Student First Name *
Student Last Name *
Student School ID Number
Student Street Address *
Student City, State Zip *
Student Grade Level *
Student Date of Birth *
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Student Race/Ethnicity *
Student Gender *
By signing below, I attest that:
A. I authorize the school system to conduct collection and testing of my child or me(if student age 18 or older) for Covid-19 by nasal swab.

B. I acknowledge that a positive test result is an indication that my child or me(if student age 18 or older), must self-isolate and also continue wearing a mask or face covering as directed in an effort to avoid infecting others.

C. I understand the school system is not acting as my child's medical provider, this testing does not replace treatment by my child's medical provider, and I assumer complete and full responsibility to take appropriate action with regards to my child's test results. I agree I will seek medical advice, care and treatment from my child's medical provider if I have questions or concerns, or if their condition worsens.

D. I understand that, as with any medical test, there is the potential for a false positive or false negative Covid-19 test result.

I, the undersigned have been informed about the test purpose, procedures, possible benefits and risk, and I have received a copy of this Informed Consent. I have been given the opportunity to ask questions before I sign, and I have been told that I can ask additional questions at any time. I voluntarily agree to this testing for Covid-19.
Date *
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Parent/Guardian Signature     [Type your name to electronically sign this form] *
Student(if age 18 or over) Signature     [Type your name to electronically sign this form]
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