The law allows some information about your child to be shared with and among certain New York State agencies and their contracted service providers, including those listed below. This information will be shared only for public health purposes, which may include notifying close contacts of your child if they have been exposed to COVID-19, and taking other steps to prevent the further spread of COVID-19 in your school community. 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(s), teacher(s), classroom/cohort/pod, enrollment and attendance history, and afterschool 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 so in accordance with applicable law and policies protecting student privacy and the security of your child’s data.
• NYS Department of Education • NYS Department of Health • Washington County Public Health
By 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 consent for my child to be tested for COVID-19 infection. • I understand that my child may be tested at multiple times through September 30, 2021, and that testing may occur (1) on days scheduled by the Whitehall Central School District in accordance with state mandates, such as weekly testing in schools in Yellow Zones, or (2) if they exhibit one or more symptoms of COVID-19, or (3) if they are a close contact of a student, teacher, or staff person with COVID-19 infection. • I understand that this consent form will be valid through September 30, 2021, unless I notify the designated contact person from my child’s school *in writing* that I revoke my consent. • I understand that if I revoke my consent or refuse to sign, my child may be required to continue their education via remote learning. • I understand that my child’s test results and other information may be disclosed as permitted by law. • I understand that if I am a student age 18 or older, or may otherwise legally consent for my own health care, references to “my child” refer to me and I may sign this form on my own behalf
Digital Signature Parent / Guardian* (if child is under age 18)
Date Signed *
Digital Signature of Student (if age 18 or over or otherwise authorized to consent)
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