HFM Special Education COVID-19 Testing Consent Form
New York State’s Cluster Action Initiative and the New York State Department of Health require schools providing in-person instruction to test specific percentages of students, teachers, and staff for COVID-19 if the school is in a designated Yellow, Orange, or Red zone.

Currently HFM BOCES is not in a designated zone and testing is not required. It is possible, however, that our region, or part of our region, may be designated a zone in the future. To be prepared for this possibility, we are reaching out now to ask for your consent for your child to be tested if testing becomes required to keep in-person instruction available.

To help us be prepared, please consider giving your consent by filling out the form below. Only students whose parents/guardians have provided consent will be tested. Please note, fully remote students will not be tested and do not need the form completed.

If testing becomes required, BOCES will use the BinaxNOW COVID-19 test for students. Testing will be administered randomly and parents will be given notice prior to the test being given. The testing process will involve a short swab that goes in the front of the nose. The tests will be conducted at the BOCES program by a medical professional. There is no cost to families for these tests.
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Student's full name *
Parent/guardian name *
Parent/guardian address *
Parent/guardian telephone number *
What program does your child attend? *
What is your child's home school district? *
The law requires and/or allows some information about your child to be shared with and among certain local County and New York State Public Health Agencies and their service providers. This information will be shared only for public health purposes. Information about your child that may be shared with these agencies and service providers conducting COVID-19 testing includes your child's name and COVID-19 test results, date of birth/age, gender, race/ethnicity, school name, teacher(s), classroom/cohort, enrollment and attendance history, and after school or other program participation, names of other family members or guardians, address, telephone, mobile number, and email address. Sharing of information about your child will ONLY be done in accordance with applicable law and county or state policies protecting student privacy and the security of your child's data.
By digitally 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 authorize HFM BOCES to test my child for COVID-19 infection.
● I understand that this consent form will be valid through June 30, 2021, unless I revoke such consent in writing.
● I authorize my child’s test results and other information to be disclosed to any governmental entity as may be required or permitted by law.
● I acknowledge that a positive test result will require my child to be sent home from school and remain at home until he/she meets the criteria to return to school according to the local County Department of Public Health.
● I understand that this testing does not replace treatment by my child’s medical provider, and I assume complete and full responsibility to take appropriate action regarding my child’s test results. I agree that I will seek medical advice, care, and treatment for my child from their medical provider if I have questions or concerns or if my child becomes ill or their condition worsens.
● I understand that, as with any medical test, there is the potential for a false positive or false negative COVID-19 test result.
By clicking ‘submit’ you hereby affirm that you are the parent/guardian of the student designated above, have the authority to make legal and/or medical decisions on behalf of such child, and have consented to COVID-19 testing performed by HFM BOCES. *
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