COVID-19 Testing Consent Form
As part of the Governor's Micro Cluster Strategy (https://forward.ny.gov/), geographic areas are designated micro cluster zones and required to implement additional COVID-19 safety measures.  These safety measures include ensuring that 20%-30% of our in-person students and staff are tested for COVID-19, in order to continue with in-person instruction.  Testing guidelines require:

1- testing every two weeks for schools located in a designated yellow zone and
2- monthly testing for schools in orange and red zones.  

If you consent, your child may be selected for testing on one or more of these occasions. No student will be tested without parental consent and all student testing is voluntary.

By signing below, I attest that:

1- I have signed this form freely and voluntarily, and I am legally authorized to make decisions for the child named above.

2- I consent for my child to be tested for COVID-19 infection.
 
3- I understand that my child may be tested multiple times through June 30, 2021.

4- I understand that this consent form will be valid through June 30, 2021, unless I notify the designated contact person from my child’s school in writing that I revoke my consent.

5- I understand that my child’s test results and other information may be disclosed as permitted by law.

6- I acknowledge that a positive test result will require my child to be sent home from school and remain at home until he/she meets the criteria to return to school according to state and local guidelines.

7- I understand that this testing does not replace treatment by my child’s medical provider, and I assume complete and full responsibility to take appropriate action regarding my child’s health and medical care as well as in response to any test results.

8- I understand that if I am a student age 18 or older, or may otherwise legally consent for my own health care, references to “my child” refer to me and I may sign this form on my own behalf.

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Parent/Guardian Last Name *
Parent/Guardian First Name *
Parent/Guardian Address *
Parent/Guardian Phone Number: *
Parent/Guardian Email Address:
Student Last Name: *
Student First Name: *
Student Date of Birth (month/day/year): *
Student Address: *
Name of Student’s School: *
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