COVID Testing Consent Form 2021-2022

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PLEASE COMPLETE ONE FORM PER CHILD.

The Biddeford and Dayton School Departments seeks to maintain a safe environment for employees, students, their families, and the community. This consent form provides the School Department or its designee with your permission to perform a COVID-19 screening test for your child at school*.

The COVID test will be administered by the school nurse. The test being conducted is the Abbot BinaxNOW, rapid antigen test. A testing sample will be collected from your child’s nose with a swab inserted into the outer cavity of each nostril. The specimen collected for a rapid test (Abbott BinaxNOW) gives results in approximately 15-20 minutes. The school or its designee will communicate the results of your child’s test to you as well as instructions on next steps. The test results will be shared with the Maine CDC for public health reporting.

* For testing purposes, students with one (1) high risk or two (2) or more low-risk symptoms will be tested for COVID-19. For example, if a student has only congestion as a symptom then they would not be a candidate to obtain a test in school. Low-risk symptoms include: new headache, runny nose/congestion, or nausea/vomiting/diarrhea beyond typical symptoms (i.e. allergies). High risk symptoms include: new cough, shortness of breath or difficulty breathing (not exercise-induced asthma), new loss of taste or smell, fever (100.4 or higher), chills, rigors, or sore throat.

Email *

Student's Last Name *

Student's First Name *

Student's Grade *

Pre-K

Kindgergarten

1st Grade

2nd Grade

3rd Grade

4th Grade

5th Grade

6th Grade

7th Grade

8th Grade

9th Grade

10th Grade

11th Grade

12th Grade

Student's School *

Dayton Consolidated School

Biddeford Middle School

Biddeford Regional Center of Technology

Biddeford High School

Biddeford Primary School

Alternative Pathways Center

Biddeford Intermediate School

John F. Kennedy School

Other:

Student's Date of Birth *

YYYY

I have read or had explained to me the COVID-19 Testing Information Statement, above, and have had the opportunity to seek answers to my questions about the risks and benefits of this test. *

I CONSENT to my child receiving the COVID-19 Test by Biddeford or Dayton School Department's School Nurse. (If this consent form is not signed, then your child will not receive the test.)

I Do NOT CONSENT to my child receiving the COVID-19 Test by the Biddeford or Dayton School Department's School Nurse.

Electronic Signature

I acknowledge and agree that this agreement shall be executed by electronic means and electronic signature, which signature shall be considered as an original for all purposes and shall have the same force and effect as an original signature. Without limitation, “electronic signature” shall include faxed versions of an original signature or electronically scanned and transmitted versions (e.g., via PDF email) of an original signature.

Please type your full legal name to represent your signature *

Relationship to the student *

Date Completed *

YYYY

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