Change in Status for SHIELD COVID-19 Testing & Release of Records

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Northbrook School District 28 (“School District”) has partnered with the University of Illinois (“Testing Partner”) to test School District students, teachers, and staff members for COVID-19 infection. Please complete this form if you wish to change the opt-in or opt-out status of you child. An individual form must be completed for each child. Change requests are not immediate; requests must be submitted by noon on Friday so we are able to update our records for the following week.

Parent/Guardian Full Name *

Home address

Parent/Guardian Mobile Number *

Parent/Guardian email address *

Best way to contact you: *

mobile number

Child/Student Last Name *

Child Student First Name *

Child/Student Date of Birth *

YYYY

Child/Student School *

Greenbriar

Meadowbrook

Westmoor

Young Explorers

NBJH

Child/Student Home address *

Child/Student ID number (if you know it)

By selecting the option below, I attest that: I have submitted this form freely and voluntarily, and I am legally authorized to make decisions for the child named above. *

I DO NOT consent for my child to be tested for COVID-19 infection.

I CONSENT for my child to be tested for COVID-19 infection

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