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COVID-19 Student Test Consent Form
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* Indicates required question
Student's First Name
*
Your answer
Student's Last Name
*
Your answer
Student's Year Group
*
Your answer
Student's Date of Birth
*
MM
/
DD
/
YYYY
Student's Gender - this information is needed for Department for Health and Social Care research purposes.
*
Male
Female
Student's Ethnicity - this information is needed for Department for Health and Social Care research purposes.
*
Asian or Asian British
Black, African, Black British or Caribbean
Mixed or multiple ethnic groups
White
Prefer not to say
Is student currently showing any COVID-19 symptoms
*
Yes
No
Student's Home Address and Postcode
*
Your answer
Email Address - this is where test results will be sent
*
Your answer
Mobile Number - this is where test results will be sent. Please do not put a landline number - you can only receive test results to a mobile number.
*
Your answer
Is the mobile number given above you main contact number?
*
Yes
No
If the mobile number given above is not your main contact number, please give your main contact number below (or N/A if not applicable).
*
Your answer
Name of parent/guardian giving consent
*
Your answer
Relationship to student
*
Your answer
Do you give consent for your child to have a COVID-19 Lateral Flow Test
*
Yes
No
Signature (typing out your name is sufficient if you are filling in this form digitally)
*
Your answer
Today's date
*
MM
/
DD
/
YYYY
Details of any health or accessibility issues which might affect a child's safe participation in the testing exercise
*
Your answer
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