Test to Stay Rapid Testing Consent Form (Each students needs their own form.)
I understand that completion of this form is the approval and consent for your child to participate in the Bronzeville Academy Test to Stay program.
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Date *
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I give permission for my child to take a rapid COVID-19 test at the school as part of the Test to Stay program. (Initial Below) *
RISKS AND BENEFITS OF TESTING I acknowledge that I have been informed and that I understand the risks and benefits associated with the test, including the possibility of a slight discomfort in the nose and/or throat, the possibility of bleeding from the nose and the possibility of an inaccurate test result. I acknowledge that I have been informed and I understand that, as with any medical test, there is the possibility of a false positive or a false negative result. I understand that the testing unit does not replace treatment by my medical provider and I hereby assume complete and full personal responsibility to take appropriate action with regard to my test results in accordance with applicable CDC guidelines (https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/isolation.html). I agree that I will seek medical advice, care and treatment from my medical provider if I have any questions or concerns. (Initial Below) *
Student First Name (Only one student per form.) *
Student Last Name (Only one student per form.) *
Student Birth Date *
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Student's Grade Level *
Parent Name *
Parent Signature (Type your name as signature) *
Parent/Guardian Contact E-mail *
Parent/Guardian Phone Number *
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