Sunday, 9:15am Covid-19 Testing Consent

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All fields must be completed in order to be eligible for testing.

Email *

Symptomatic Individual's First Name *

Symptomatic Individual's Last Name *

Gender *

Date of Birth *

YYYY

Race *

American Indian or Alaska Native

Black or African American

Native Hawaiian or Other Pacific Islander

White

Other

Ethnicity *

Not Hispanic or Latino

Hispanic or Latino

Street Address *

State *

INDIANA

Other:

Zip Code *

City *

County *

Hancock

Shelby

Hamilton

Henry

Marion

Other:

Telephone Number - NO DASHES, NUMBERS ONLY - example 3174629211 *

Are you experiencing any covid symptoms today? *

Yes

ACCEPTANCE: I have been informed about the test purpose, procedures, possible benefits, and risks, and I have retained a copy of this authorization and consent for my records. I have been given the opportunity to ask questions before I sign, and I understand I can revoke this authorization at any time. This authorization and consent is written in a manner that can be clearly understood and I knowingly and voluntarily agree for my child to be tested for COVID-19 per the school’s policy. *

Yes

I acknowledge that a positive test result will not allow my child to enter the school or participate in that school’s activities. A positive test result will also require my child to abide by the school's COVID-19 policies and all applicable federal, state, county, and/or local guidance on COVID-19 to promote the safety and welfare of others. *

Yes

I give consent for Covid-19 testing to be performed according to protocols and understand that results will be reported to the Indiana State Department of Health. Testing is not a substitute for medical treatment, and I assume full responsibility for any medical care necessary. I will notify my healthcare provider with test results and with any questions or concerns I have related to the results. I understand that by signing this consent and authorizing COVID-19 testing of my child that my child is not and will not become a patient or receive any medical care from the school or any affiliated tester acting on the school’s behalf. I further understand that the school or any affiliated tester acting on the school’s behalf is not offering to act or acting as a medical provider for my child. *

Yes

I understand that, as with any test, there is the potential for false positive or false negative test results to occur and retesting may be necessary. *

Yes

I authorize my child’s COVID-19 test results to be disclosed to the school where my child will be entering and/or participating in activities and to any pertinent local, county, state, or other governmental entity as may be required by law, and I understand that such disclosure of my child’s test results will also be made consistent with applicable law.

Yes

Clear selection

Full Name - This serves as your electronic signature for consent to be tested. *

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