SHIELD Testing in District 25
Please read the consent document pictured below and complete the questions on this google form.
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Email *
SHIELD Consent Form | Page 1
SHIELD Consent Form | Page 2
Staff/Student First Name *
Staff/Student Middle Initial
Staff/Student Last Name *
Staff/Student Date of Birth *
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Staff/Student Sex *
Staff/Student Ethnicity
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Staff/Student 1st Race
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Staff/Student 2nd Race
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Staff/Student Mailing Address *
Staff/Student School *
Phone Number *
Parent/Guardian Name *
Write "n/a" if you are a staff member/adult filling this out.
OUTBREAK: Are you registering for SHIELD in response to a particular situation like a classroom outbreak?
You would have received an email prompting you to sign up for SHIELD.
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Please confirm: *
Required
Date this form was signed: *
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A copy of your responses will be emailed to the address you provided.
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