Affirmation of Over The Counter COVID-19 Antigen Test Result to Return to School

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Please complete this form prior to your child's return to school if they have been exhibiting symptoms of COVID-19.
***NOTE, tests must be given at least 36 hours (1.5 days) apart ***

Over the Counter tests combined with the completion of this form will be accepted in place of a note from your child's doctor or a lab test.

Email *

Child's Name and Grade *

Vaccination Status *

Vaccinated

Not Vaccinated

Child's Date of Birth *

YYYY

Test #1 Date *

YYYY

Test #1 Time *

Time

Test #1 Result *

Negative

Positive

Test #2 Date *

YYYY

Test #2 Time *

Time

Test #2 Result *

Negative

Positive

I do hereby affirm that my child has tested negative on TWO OTC COVID-19 antigen tests at least 36 hours (1.5) days apart and has a resolution of symptoms permissible to return to school. *Please enter your name in the space below to attest that the information you have provided is accurate and true. *

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