COVID-19 SCHOOL-BASED TESTING CONSENT and ADMINISTRATION RECORD
Wisconsin Heights School District is using this form to receive your consent to test your child for COVID-19 and to share collected data with relevant authorities.

What is the test?
With your consent, your child will receive a free diagnostic test for the virus that causes COVID-19. Collecting a specimen for testing involves inserting a small swab, similar to a cotton swab, into both nostrils.

How will I find out about the results of the test?
If your child has a specimen collected for testing at school, you will be notified of the test result or informed of how the test result will be received (for example: by phone, text, or email).

What should I do when I receive my child’s test results?
If the test is positive, this means that the virus was detected in your child’s specimen. You will hear from your child’s school or a trained professional about this test. You will be asked to pick up your child and you will be provided information about keeping your child home, following up with your health care provider, and when your child can return to school.
If your child’s test results are negative, this means that the virus was not detected in your child’s specimen at this time. You will be asked to follow the instructions provided by your child’s school following this test result.

YOU WILL BE NOTIFIED PRIOR TO TESTING YOUR CHILD.

Visit the CDC’s Coronavirus webpage for more information on the disease and keeping you and your family
safe: www.cdc.gov/coronavirus.
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Email *
I have signed this form freely and voluntarily, and I am legally authorized to make decisions for the child named below *
Required
I consent that the school may notify my child of the test results (parent will be notified first). This may be applicable in some situations if the child is at school. *
Required
I consent for my child to be tested for COVID-19 when necessary and understand that my child may be tested multiple times. *
Required
I consent for my child to be tested by school staff, contracted healthcare personnel, Local and Tribal Health Department staff, and/or other trained personnel as directed by the school. I understand that if my child is between the ages of 14-17, they will be asked to provide verbal consent to be tested. *
Required
I understand that this consent form will be valid through June 30, 2022, unless I notify the designated contact person from my child’s school in writing that I revoke my consent. *
Required
I understand that test results may be shared with the school, the ordering physician, county, and other local, state, and federal public health authorities, as well as other testing partners as permitted by law. *
Required
I understand that if I am a student age 18 or older, or may otherwise legally consent for my own healthcare, references to “my child” refer to me and I may sign this form on my own behalf. *
Required
Student Name *
Grade
Parent/Guardian Signature (parent/guardian or student if 18 years of age or older) DISCLAIMER: By typing your name below, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature. *
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