District 289 Student: COVID Testing Authorization
STUDENT: Consent Form for COVID-19 Testing & Release of Records

What is this form?
We are seeking your consent to test your child for COVID-19 infection.  Mendota Elementary District 289  has partnered with the University of Illinois to test School District students, teachers, and staff members for COVID-19 infection.

How often will your child be tested?
We are arranging for our Testing Partner to test the students at least 1 time per week.

What is the test?
If you consent, your child will receive a free diagnostic test for the COVID-19 virus conducted by collecting saliva (spit).

How will I know if my child tests positive?
You will receive access to your child’s test results via an online platform which we will separately send you information about in future correspondence. [Mendota Elementary District 289 will also receive results of your child’s test and may/will notify you separately of any positive result.]

What should I do when I receive my child’s test results?                                                              
If your child’s test results are positive, please contact your child’s doctor immediately to review the test results and discuss next steps. You may not send your child back to school without a release letter from the Local Health Department.

If your child’s test results are negative, this means that the COVID-19 virus was not detected in your child’s saliva (spit).

Tests sometimes produce incorrect negative results called “false negatives” in people who have COVID-19.  If your child tests negative but has symptoms of COVID-19, or if you have concerns about your child’s exposure to COVID-19, you should call your child’s doctor.

Who will receive my child’s test results?                                                                                      
In addition to you receiving your child’s test results, the School District and the Illinois Department of Public Health (“IDPH”) will also receive your child’s test results, consistent with IDPH guidance and the Illinois Control of Communicable Disease Code.

*IF YOU DO NOT WANT YOUR CHILD TO PARTICIPATE IN SHIELD COVID TESTING AT SCHOOL - DO NOT FILL OUT THE FOLLOWING FORM*

Note: If you have more than 1 child attending Mendota Elementary - A SEPERATE FORM MUST BE FILLED OUT FOR EACH CHILD

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Email *
Child's Name (Last, First) *
Child's Grade Level *
Date of Birth for Child *
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Sex of Child
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Parent/Guardian Name (Last, First) *
Phone Number of Parent/Guardian
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 for my child to be tested for COVID-19 infection.                                                                                      I understand that my child may be tested multiple times through the 2021-2022 school year, and that testing will occur at least 1 time per week.                          I understand that this consent form will be valid through the 2021-2022 school year, unless I notify the designated contact person from my child’s school in writing that I revoke my consent.                                          I understand that my child’s test results and other information may be disclosed as permitted by law.             I hereby give consent for Mendota Elementary District 289 to perform SHIELD saliva testing for COVID 19. *
Digital Signature *
Date *
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A copy of your responses will be emailed to the address you provided.
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