Student Consent Form: COVID-19 Information

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1. VACCINATION STATUS:

Parents are asked to provide documentation of vaccine status for their child so we may appropriately identify "close contacts" exempt from COVID-19 testing and quarantine protocols in the event a student or staff member tests positive for COVID-19 this school year. Vaccination is a key mitigation strategy as we work to provide a healthy and safe learning environment in our school community.

If a parent elects not to share the vaccine status of their child, the child must follow COVID-19 test and quarantine protocols for unvaccinated individuals.

2. TEST AND STAY:

Parents are asked to provide consent for their child to participate in Test and Stay protocol. The Test and Stay protocol is a key mitigation strategy as we work to provide a healthy and safe learning environment for students and staff in the North Middlesex Regional School District.

If a parent elects not to have their child participate in the Test and Stay Program, the child must follow the traditional COVID-19 test and quarantine protocols if identified as a close contact to a COVID-19 positive case.

3. POOL TESTING

At this time NMRSD is NOT participating in Pool Testing based on our analysis of the 2020-2021. NMRSD is asking parents to consent to Pool Testing below if NMRSD chooses to bring this program to the district in the future. Pool testing is strongly encouraged and recommended for unvaccinated individuals. Participation in Pool testing is not recommended for vaccinated individuals.

A signed consent is required for both the Test and Stay and Pool Testing Programs. Please complete ONE FORM for each child you have in the district by 9/15/2021.

PLEASE NOTE: The district is still working with DESE and DPH to set up the Test and Stay option. A district email will be sent out once testing is available.

Email *

Student's First Name *

Student's Last Name *

What K-12 school does your child attend (Please complete a separate form for each child in your family)? *

Ashby Elementary School

Spaulding Memorial School

Varnum Brook Elementary School

Hawthorne Brook Middle School

Nissitissit Middle School

NMRHS/Gateway

What grade is your student in? *

Kindergarten

Grade 1

Grade 2

Grade 3

Grade 4

Grade 5

Grade 6

Grade 7

Grade 8

Grade 9

Grade 10

Grade 11

Grade 12

Gateway

Vaccination status: My child is... *

Fully vaccinated, I will send in a copy of my child's vaccination card to the school nurse (either a photocopy or scanned email to the school nurse).

No, my child is not vaccinated at this time.

I prefer not to answer and will abide by quarantine guidelines for any close contact identification or positive test results.

I consent for my child to participate in the Test and Stay protocol. *

Yes

No, not at time.

I consent for my child to participate in pool testing, if NMRSD chooses to bring this program to the district at a later time. *

Yes

No, not at this time.

Please write your name below indicating who completed this form on behalf of their child. *

Please select the link below to be directed to the CIC Health Platform to provide consent (or opt out) for your child to participate in weekly COVID-19 the Test and Stay Program and/or possible future Pool Testing. After you complete in the CIC Platform, return to this form and select "Submit" to complete the registration. (Please make sure to understand CIC "Consent" allows an opt-out. Please scroll down on their page to see all directions) *

https://www.cic-health.com/consent/ma?district=null

A copy of your responses will be emailed to the address you provided.

Submit

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