St. Joseph CCSD #169 Optional COVID-19 Testing Program Parent/Guardian Consent Form

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St. Joseph CCSD #169 will begin conducting optional BinaxNOW POC antigen testing for students and staff. This program is being offered only as a convenience for our parents, and we will never test anyone without the proper consent. We ask that you sign the consent form so we have a written record if you would like to take advantage of this program, but also know that the school nurse will contact you before any test is administered for your verbal consent as well. We will also immediately contact you with the results of test to determine what if anything needs to happen next.

Things that you should know:

• The BinaxNow Antigen test is a rapid test that will provide results in 15 minutes.
• Once the test is administered students will wait in our safe room for results to determine proper course of action.
• We are required to share results the Champaign-Urbana Public Health Dept.
• By signing below, you are indicating that you voluntarily consent to this procedure for the detection of COVID-19 for you student.
• The signing below, you agree on behalf of you minor student to hold harmless, and indemnify the school district and its employees and agents from any claims arising out of the participation in the testing, including but not limited to any inaccurate testing results.

If you have any questions about the testing, please contact St. Joseph CCSD #169 District nurse, Katie May at mayk@stjoe.k12.il.us or (217) 469-2291 or feel free to discuss the proposed testing with your physician, to learn about the purpose, potential risks, and benefits of any testing.

School Name *

St. Joseph Grade School

St. Joseph Middle School

Student's First Name *

Student's Middle Initial *

Student's Last Name *

Student's Birthdate *

YYYY

Student's Sex *

Male

Female

Other

Unknown

Student's Ethnicity *

Hispanic

Non-Hispanic

Unknown

Student's Race *

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or other Pacific Islander

White

Other Race/Multiracial

Unknown

Student's Street Address (Street, City, Zip) *

Parent's Phone Number (please include area code) *

Parent's Name (First and Last) *

I give consent for St. Joseph CCSD #169 to conduct the BinaxNOW rapid POC antigen testing on my child named above. *

Yes

Parent Signature *

Date *

YYYY

Submit

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