Over the Counter Covid-19 Antigen Test Result to Return to School For Students

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

This form must be completed and submitted for your student to return to school.

I hereby affirm that my child has tested negative on TWO Over-the-Counter COVID-19 antigen tests at least 36 hours (1.5 days) apart and has a resolution of symptoms permissible to return to school.

Parent/Guardian Name: *

Student Name: *

Date of Birth: *

YYYY

Building *

Over the Counter Test Name Brand: *

Test #1 Date: *

YYYY

Test #1 Time: (Please include am/pm) *

Time

Result *

Negative

Positive

Over the Counter Test Name Brand: *

Test #2 Date: *

YYYY

Test #2 Time (Please include am/pm) *

Time

Result: *

Negative

Positive

By providing my e-signature, I am affirming that my child's symptoms are resolving. I also understand that should symptoms worsen or new symptoms arise, my child may be sent home. If the home test was positive, my child will wear a tight fitting mask for the reminder of the ten days. Signed: *

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Hudson Falls Central School District.

Does this form look suspicious? Report

Forms