JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
September 2021 Consent Form - Covid 19 LTD testing
By completing this consent form, you are agreeing to all of the statements in this guidance. If you have previously given your consent, you do not need to do so again.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Surname of student being tested
*
Your answer
First name(s) of student being tested
*
Your answer
Date of birth
*
MM
/
DD
/
YYYY
Gender (This information is needed for DHSC research purposes)
*
Male
Female
Ethnic Group (This information is needed for DHSC research purposes)
Asian or Asian British
Black
African
Black British
Caribbean
Mixed or multiple ethnic groups
White
Clear selection
Year group
*
Year 7
Year 8
Year 9
Year 10
Year 11
Year 12
Year 13
Name of person completing this form (This should be the name of a parent or Guardian if under 16)
*
Your answer
Relationship to child (if under 16)
Your answer
Home Postcode
*
Your answer
House Number/Name and street name
*
Your answer
Email address
*
Your answer
House Phone Number
Your answer
Mobile Number
*
Your answer
Currently showing any Covid-19 symptoms?
*
Yes
No
NHS number if known
*
Your answer
I confirm that I have read the guidance above and give my consent to testing
*
Yes
Required
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Ormiston Rivers Academy.
Report Abuse
Forms
