Middleburgh Central School District COVID-19 Testing Parental Consent Form
Consent for Student Rapid COVID-19 Testing

Middleburgh Central School District is seeking your consent to test your child for COVID-19 infection. If you consent, your child may receive a free diagnostic test for the COVID-19 virus that will be administered by a certified or licensed medical provider (CNA, LPN, or RN). A rapid COVID-19 test will be used, which will involve inserting a small swab, similar to a Q-Tip, into the front of the nose. We will notify you if your child tests positive for COVID-19. Any student who tests positive will be sent home and must be kept at home until meeting Schoharie County Department of Public Health criteria to return to school. Please contact your child’s doctor immediately to review the test results should your child test positive for COVID-19.  

Sign in to Google to save your progress. Learn more
1. Student full First Name (not a nickname) *
2. Student Last Name *
3. Student ID Number
4. Student Date of Birth *
MM
/
DD
/
YYYY
5. School Student Attends *
6. The law requires and/or allows some information about your child to be shared with Schoharie County and New York State Public Health Agencies. This includes notifying the Schoharie County Department of Public Health about the COVID-19 results of each student who is tested, including the student’s name, date of birth, race, ethnicity, gender, address, phone number, and result of the COVID-19 test. *
Captionless Image
6. Name of Parent/Guardian Providing Consent *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Middleburgh CSD. Report Abuse