Consent & Administration Record - Two Rivers School District COVID-19 School-Based Testing Consent for 2021-2022
This form asks your permission for us to test your child if they show symptoms consistent with COVID-19 or have been in close contact with a person with COVID-19 while in school (per your request).  You must fill out a separate consent form for each child.

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Email *
Student Last Name
Student First Name
Student Middle Initial
Student Address
City
Date of Birth
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Age
Gender
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Parent Legal Name
Parent Primary Phone Number
By typing my name below, I attest that:
By signing below I attest that:
I have signed this form freely and voluntarily, and I am legally authorized to make decisions for the child named above
I consent that the school may notify my child of the test results
I consent for my child to be tested for COVID-19, when necessary.
I consent for my child to be tested by school staff, contracted healthcare personnel, Local and Tribal Health Dept 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.
I understand that this consent form will be valid through July 22, 2022, unless I notify the designated contact person from my child’s school in writing that I revoke my consent
I understand test results may be shared with the school, county, and other local, state, and federal public health authorities as permitted by law.
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.
Visit the CDC’s Coronavirus webpage for more information on the disease and keeping you and your family safe: www.cdc.gov/coronavirus 

Signature of Parent (Type Your Name In)
I would like my child's test results to be:
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Enter your email, text, or cell phone info here to be contacted at re the above question.
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