COVID-19 SCHOOL-BASED SYMPTOMATIC TESTING CONSENT FOR THE 2021- 2022 SCHOOL YEAR

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

This is consent only for students that have COVID symptoms and you are providing consent to test. This is NOT weekly screening testing.

Lansing Central School District is using this form to receive your consent to test your child for COVID-19 and to share collected data with relevant public health authorities.

Why test?
Testing will help reduce community spread of COVID-19 and ensure that our schools are safe learning and working environments. The testing of students will assist the district in quickly identifying COVID-19 positive cases, which is critical to preventing school outbreaks.

What is the test?
With your consent, your child will receive a free diagnostic test for the virus that causes COVID-19. Currently the School District COVID-19 testing program will offer a PCR test to any student that is exhibiting COVID-19 symptoms while at school. Collecting a specimen for testing involves inserting a small swab, similar to a cotton swab, into both nostrils or collecting saliva in a tube. Testing will only take place if parent/guardian consent has been given.

How will I find out about the results of the test?
If your child has a specimen collected for testing at school, you will be notified of the test result or informed of how the test result will be received (for example: by phone, text, or email).

What should I do when I receive my child’s test results?
If the test is positive, this means that the virus was detected in your child’s specimen. You will hear from the Health Department about this test. You will be asked to pick up your child (or not send your child to school) and you will be provided information about keeping your child home, following up with your health care provider, and when your child can return to school.

If your child’s test results are negative, this means that the virus was not detected in your child’s specimen at this time. You will be asked to follow the instructions provided by your child’s school following this test result.

Email *

Building *

Elementary School

Middle School

High School

Student Last Name: *

Student First Name: *

Student Address:

Student Date of Birth: *

YYYY

Parent/ Legal Guardian Name:

By signing below, I attest that: I have signed this form freely and voluntarily, and I am legally authorized to make decisions for the child named above. I consent that the school may notify my child of the test results. I consent for my child to be tested for COVID-19 when necessary and understand that my child may be tested multiple times. I consent for my child to be tested by school staff, contracted healthcare personnel, Local and Tribal Health Department staff, and/or other trained personnel as directed by the school. I understand that this consent form will be valid through July 31, 2022, unless I notify the school administrator from my child’s school in writing that I revoke my consent. I understand that test results may be shared with the school, county, and other local, state, and federal public health authorities as permitted by law. I understand that if I am a student age 18 or older, or may otherwise legally consent for my own health care, references to “my child” refer to me and I may sign this form on my own behalf. Visit the CDC’s Coronavirus webpage for more information on the disease and keeping you and your family safe: www.cdc.gov/coronavirus. *

Yes, I attest to the above statements.

Today's Date *

YYYY

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Lansing Central School District. Report Abuse

Forms