Test and Trace Consent Form (Student)

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电子邮件地址 *

Student's First Name *

Students Surname *

Student's Tutor Group *

Student's Date of Birth *

年

月

日

Gender at birth *

Male

Female

Students Ethnic Group

Black African

Bangladeshi

White British

Black Caribean

Chinese

Gypsy/Roma

Indian

White Irish

Pakistani

Traveller of Irish Heritage

White and Asian

White and Black Caribbean

Any other Asian background

Any other black background

Any other white background

Other

I do not wish to answer

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Home Postcode *

First line of Home address

Parent / Carer Email Address *

Parent / Carer Mobile number *

I consent to my child having a nose and throat swab for a lateral flow test *

Yes

I consent that my child's sample will be tested for the presence of Covid-19 *

Yes

If the lateral flow test indicates the presence of Covid-19, I consent to my child having a nose and throat swab for confirmatory PCR testing, which shall be sent the same day to an accredited clinical diagnostics laboratory run by Public Health England (PHE) with results available within 24-48 hours. *

Yes

I consent that they will need to self-isolate following the PCR test until the results have been received. *

Yes

Parent / Carer's Full Name *

Relationship to child *

Today's date *

年

月

日

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