Consent for Testing Form
What is this form?
We are seeking your consent to testing your child for COVID-19 infection. The New York City Department of Education (NYC DOE), working with NYC Health + Hospitals and the New York City Department of Health and Mental Hygiene, has partnered with laboratories and other providers to test NYC DOE students, teachers, and staff members for COVID-19 infection.
*Merrick Academy Charter School will be participating in the bi-weekly testing of students in grades 1-5.
How often would you test my child?
We are arranging for our laboratory and provider testing partners to come to our school bi-weekly to test 10% of the students in grades 1st-5th. If you consent, your child may be selected for testing on one or more of these occasions. In addition, your child may also be tested throughout the school year (1) in accordance with state and city 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.
What is the test?
If you consent, your child will receive a free diagnostic test for the COVID-19 virus. Collecting a specimen for testing involves inserting a small swab, similar to a Q-Tip, into the front of the nose.
How will I know if my child tests positive?
If your child has a specimen collected for testing at school, we will send information home with them to let you know. COVID 19 test results will generally be provided within 48-72 hours.
What should I do when I receive my child’s test results?
If your child’s test results are positive, please contact your child’s doctor immediately to review the test results and discuss what you should do next. You should keep your child at home and inform us by emailing
. If your child’s test results are negative, this means that the virus was not detected in your child’s specimen. Tests sometimes produce incorrect negative results (called “false negatives”) in people who have COVID-19.
If your child tests negative but has symptoms of COVID-19, or if you have concerns about your child’s exposure to COVID-19, you should call your child’s doctor and contact your school. If you need help finding a doctor, call (844) NYC-4NYC.
Parent/Guardian Tel./Mobile #
Parent/Guardian Email address:
Best way to contact you
Child/Student Print Name:
Child/Student School ID/OSIS #:
Child/Student Date of Birth:
Child/Student Home Address:
The law allows some information about your child to be shared with and among certain New York City and New York State agencies and their contracted service providers. 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 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 so in accordance with applicable law and City policies protecting student privacy and the security of your child’s data.
By selecting yes and initially 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 June 30, 2022, and that testing may occur on days scheduled by Merrick Academy or the NYCDOE in accordance with state and city mandates.
• I understand that this consent form will be valid through June 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. Test results may be shared with Merrick Academy Testing Coordinators, Administration and necessary staff ONLY for the purposes of tracing and health purposes. This information is to remain confidential from person(s) that are not legally deemed to receive it.
I agree that if my child has a positive result from testing this information will be released to the school testing coordinators by the testing company.
• 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.
Yes, I give consent for my child to be tested.
No, I decline consent. I understand my child will not be allowed to attend school "in- person" learning at Merrick Academy Charter School. I understand that Merrick Academy has not planned to offer remote learning for the 2021-22 school year.
Signature INITIAL of Parent/ Guardian* (if child is under age 18)
A copy of your responses will be emailed to the address you provided.
Never submit passwords through Google Forms.
This form was created inside of Merrick Academy Charter School.