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Lord Derby Academy
Consent Form
This form is for:
-
Pupils for whom consent was not previously given or withdrawn
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* Indicates required question
Pupil First Name
*
Your answer
Pupil Surname
*
Your answer
Year Group
*
7
8
9
10
11
Required
Pupil Date of Birth
*
MM
/
DD
/
YYYY
Pupil Gender – this information is needed for Department for Health and Social Care research purposes.
*
Male
Female
Prefer not to say
Required
Pupil Ethnicity (this information is needed for Department for Health and Social Care research purposes)
*
Choose
Asian or Asian British
Black, African, Black British or Caribbean
Mixed or multiple ethnic groups
White
Prefer not to say
Currently showing any COVID-19 symptoms?
*
Yes
No
Required
Home Postcode
*
Your answer
First Line of Home Address
*
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
Email Address – this is where test results will be sent
*
Your answer
Name of parent/guardian giving consent
*
Your answer
Relationship to test subject
*
Your answer
Signature (typing out 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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