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Pupil Covid-19 Testing Consent Form
September 2021
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* Indicates required question
First Name
*
Your answer
Last Name
*
Your answer
Year group
*
Year 7
Year 8
Year 9
Year 10
Year 11
Date of Birth
*
MM
/
DD
/
YYYY
Gender - this information is needed for Department of Health and Social Care research purposes
*
Male
Female
Ethnicity - this information is needed for Department for Health and Social Care research purposes
*
Asian or Asian Black
Black, African, Black British or Caribbean
Mixed or Multiple ethnic groups
White
Prefer not to say
Currently showing any COVID-19 symptoms?
*
Yes
No
Home Postcode
*
Your answer
First line of your address (eg 1, Hilsbrook Ave)
*
Your answer
Email address - this is where test results will be sent
*
Your answer
Mobile Number - this is where test results will be sent. Please do not put a landline number - you can only receive test results to a mobile number
*
Your answer
I consent to having / my child having a nose and throat swab for lateral flow tests, (Type name to give consent)
*
Yes
Relationship to test subject
*
Your answer
Signature (typing your name is sufficient if you are filling in this form digitally)
*
Your answer
Today's Date
*
MM
/
DD
/
YYYY
Details of any health or accessibility issues which might affect a child's safe participation in the testing exercise
*
Your answer
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