WCPS VISSTA Program Consent Form

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

By completing and submitting this form, I confirm that I am the appropriate parent / legal guardian to provide consent, and that I authorize the collection of specimens necessary to conduct COVID-19 testing on my student during school hours or in connection with school attendance/ a school activity. I understand that authorizing COVID-19 testing for my student is optional and that I can refuse to give this authorization, in which case, my student will not be tested. COVID-19 screening testing will be conducted using a pooled PCR testing method. Screening testing will be conducted by a contracted vendor or school personnel. Diagnostic testing (including testing of close contacts), may be conducted using BinaxNOW antigen tests proctored through a brief telehealth visit with a contracted vendor, in addition to utilizing PCR testing.

Student's Last Name *

Student's First Name *

Student's Middle Name

Student's Date of Birth *

YYYY

Student's Street Address (No PO Boxes) *

Student's City *

Parent's Phone *

Parent's E-Mail

Student's Gender *

Male

Female

Nonbinary

Prefer not to say

Student's Race *

American Indian/Alaskan Native

Asian

Black or African American

Hawaiian Native or Other Pacific Islander

White

Not Stated

Required

Is the student Hispanic/Latino *

Yes

Student's School *

Student's Homeroom Teacher *

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Wise County Public Schools. Report Abuse

Forms