IRCSD COVID-19 On-Demand Testing Consent for Students
*PLEASE NOTE* If you DO NOT CONSENT to having nursing staff conduct a rapid test for COVID-19 on your child, there is no need to complete this form.

Please fill out a separate form for each student.

This form will give Indian River Central School District permission to screen your child for COVID-19 by performing a simple, non-invasive COVID-19 rapid test. This consent is separate from the earlier request related to potential yellow-designation testing of 20% of the population.

In this case, COVID-19 testing will be performed by IRCSD nursing staff on-demand/as needed. If a student is seen in the nurse's office after developing symptoms of COVID-19, the school nurse will call the student’s parent/guardian for final permission prior to performing the test. (It is important to note that students should NOT be sent to school with symptoms, but we do realize that symptoms do sometimes appear during the school day.)

Parents will be notified immediately if their student tests positive for COVID-19 and will be required to pick the student up from school.

This form will be used for the 2020-21 school year and will expire on June 30, 2021.
Student First Name *
Student Last Name *
School Building *
Street Address *
City *
Zip Code *
County *
Parent Phone Number *
Student Date of Birth *
Student Age *
Student Gender *
Student Race *
Electronic Signature Consent
I give permission for my child to be screened for COVID-19 at school. I understand if my child tests positive, I will be required to pick him/her up from school.

By selecting "I APPROVE" below, I attest that:
*I have signed this form freely and voluntarily and I am legally authorized to make decisions for the child named in this form.
*I understand that this consent form will be valid through June 30, 2021, unless I revoke such consent in writing.
*I understand that my child's test results and other information will be disclosed as permitted by law to NYSDOH.
*I understand that should my child test positive for COVID-19, he/she will not be permitted to return to school until the Jefferson County Health Department criteria for returning to school is met.
*I understand that should my child test positive for COVID-19, I must contact my child's Healthcare Provider immediately to review the results.
Student Name *
Please type the full name of your child.
Parent/Guardian Electronic Signature *
Please type your full name.
Date *
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