Fort Leavenworth School District Informed Consent For Student COVID-19 Rapid Antigen Testing
Please complete one form for each student.
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Email *
Student Last Name *
Student First Name *
Student Date of Birth *
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Student Grade Level *
Student School of Attendance *
Parent/Guardian Full Name *
Parent/Guardian Phone Number *
Parent/Guardian Address *
Consent *
Required
Signature of Parent/Legal Guardian  **By typing your name, it acts as a signature** *
Today's Date *
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DD
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A copy of your responses will be emailed to the address you provided.
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