BCSD Consent for Student Rapid COVID-19 Testing

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The Batavia City School District (the “District”) must randomly select and test faculty, staff, and students in order to maintain in-person, hybrid instruction. The District is seeking your consent to test your child for COVID-19 infection. If you consent, your child may receive a free diagnostic test for the COVID-19 virus that will be administered by a trained staff, or a licensed practical nurse (LPN) or registered nurse (RN).

A rapid COVID-19 test will be used, which will involve inserting a small swab, similar to a Q-Tip, into the front of both nostrils. We will notify you if your child tests positive for COVID-19. Any students who test positive will be sent home and must be kept at home until meeting Genesee County Department of Health criteria to return to school. Please contact your child’s doctor immediately to review the test results should your child test positive for COVID-19.

The law requires and/or allows some information about your child to be shared with Genesee County and New York State Public Health Agencies. This includes notifying the Genesee County Department of Health about the COVID-19 results of each student who is tested and may include the student’s name, date of birth, race, ethnicity, gender, address, phone number, and result of the COVID-19 test.

A description of this non-invasive test can be found at: https://www.globalpointofcare.abbott/en/support/product-installation-training/navica-brand/navica-binaxnow-ag-training.html

Email *

I have read the above. *

By selecting this box you are confirming you have read the above description.

Required

Student Last Name *

Student Middle Name

Student First Name *

Student Date of Birth *

YYYY

What School Do They Attend? *

Jackson Primary

John Kennedy Intermediate

Batavia Middle School

Batavia High School

Student Grade Level *

Attestation

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 authorize the Batavia City School District to test my child for COVID-19 infection.

• I understand that my child may be tested multiple times during the 2020-2021 school year.

• I understand that this consent form will be valid through June 30, 2021, unless I revoke such consent in writing.

• I authorize my child’s test results and other information to be disclosed to any governmental entity as may be required or permitted by law.

• 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 the Genesee County Health Department.

• 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 test results. I agree that I will seek medical advice, care, and treatment for my child from his/her medical provider and that I will contact his/her medical provider if I have questions or concerns.

• I understand that, as with any medical test, there is the potential for a false positive or false negative COVID-19 test result.

Electronic Signature *

I understand and acknowledge that by checking this box, I am confirming that I have read this entire form and that the information I have provided is true and accurate. I intend for this to serve as my electronic signature and I am authorizing the District to rely on my electronic signature. I understand and acknowledge that this electronic signature has the same legally binding effect as if I had placed my handwritten signature on a paper form.

Required

Parent/Guardian Last Name (i.e., person providing consent) *

Parent/Guardian First Name (i.e., person providing consent) *

Contact Information: Please provide the best phone number to reach you at during the school day. *

Any Additional Information or Request You May Have?

A copy of your responses will be emailed to the address you provided.

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