Burns Park Parent Permission for Rapid COVID Test at School
Dear Burns Park Parent/Guardian,
AAPS school nurses and other trained personnel are able to offer free rapid antigen tests to students during pop-up testing events and on a case-by-case basis at school. The test is a swab in the lower nasal cavity. It is painless and quick. Results are ready in 15 minutes.

If you would like your student(s) to be tested during a pop-up testing event or when symptomatic at school, please fill in the form below. Fill in one form for each student you consent to be tested. Testing is voluntary and consent can be withdrawn by emailing the principal or school nurse.

More information on the MDHHS BinaxNow tests and testing program can be found here:
https://www.michigan.gov/documents/coronavirus/BinaxNOW_FAQ_706167_7.pdf

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Email *
Parent/Guardian 1: First and Last Name *
Parent/Guardian 1: Phone number in this format XXX-XXX-XXXX *
Parent/Guardian 1: Email address *
Parent/Guardian 1: I am a legal guardian to the student listed in this form. *
Parent/Guardian 2: FIrst and Last Name
Parent/Guardian 2: Phone number in this format xxx-xxx-xxxx
Parent/Guardian 2: Email address
Parent/Guardian 2: I am a legal guardian to the student listed in this form. *
Which school does your student attend? *
Student First Name *
Student Last Name *
Grade *
Teacher's Name *
Student's Date of Birth *
MM
/
DD
/
YYYY
Home Address *
City *
ZIP Code: 5 digit XXXXX *
The following questions are required by the Michigan Department of Health and Human Services. There is an option to select "Prefer not to answer" for each one.
Student's Sex *
Required
Student's Race *
Required
Student's Ethnicity: Hispanic/Latino *
Required
Student's Ethnicity: Arab/Middle Eastern *
Required
Consent for my child to be tested - please read carefully below or review at        http://bit.ly/ConsentTest.                        
1.    I understand that the COVID-19 testing will be conducted through a BinaxNOW antigen test, or other acceptable test as ordered by an authorized medical provider or a public health official.                                                            
2.    I understand that my ability to receive testing is limited to the availability of test supplies.                                                                                                                       3.    I understand that I am not creating a patient relationship with the ordering physician by participating in this testing. I understand the entity performing the test is not acting as my medical provider. Testing does not replace treatment by my medical provider. I assume complete and full responsibility to take appropriate action with regards to my test results and my medical care. I agree I will seek medical advice, care, and treatment from my medical provider or other health care entity if I have questions or concerns, if I develop symptoms of COVID-19, or if my condition worsens.                                  
4.    I understand it is my responsibility to inform my/my child's health care provider of a positive test result, and that a copy will not be sent to my/my child's health care provider for me.
5.    I understand that my/my child's antigen test result will be available in 15-30 minutes. If the result is positive, it may need to get the result confirmed with a PCR test.
6.    I understand and acknowledge that a positive antigen test result is an indication that I/my child needs to start isolating immediately to avoid infecting others unless/until I/my child receives a negative PCR test.    
7.    I have been informed of the test purpose, procedures, and potential risks and benefits. I will have the opportunity to ask questions before proceeding with a COVID-19 diagnostic test at the testing site or by emailing the school. I understand that if I do not wish to continue with the COVID-19 diagnostic test, I may decline to test.
8.    I understand that to ensure public health and safety and to control the spread of COVID-19, my test results may be shared without my individual authorization.                                                                                                                      
9.    I understand that my test results will be disclosed to the appropriate public health authorities as required by law.
10.  I understand that I may withdraw my consent to participate in testing at any time.                        
By checking this box, I acknowledge that I have read the consent form and give my authorization and consent for my child to participate in the rapid antigen test program administered by the school nurse or other qualified personnel at my child's school. I agree to follow instructions for my student's health based on the test results.   *
Required
We will notify parents/guardians as soon as possible with your child's test results. **PLEASE MAKE SURE YOUR EMAIL ADDRESSES AND PHONE NUMBERS ARE CORRECT IN THIS FORM.**
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