Consent for COVID-19 Rapid Antigen Testing at School in the Kinnikinnick #131 School District
ONE FORM PER STUDENT

Kinnikinnick Community Consolidated School District 131 (“District”) seeks to maintain a safe environment for employees, students, and the school community in light of the COVID-19 outbreak. This consent provides the District with your permission to perform a COVID-19 test on your student and to release your student’s identifying information and test results to the Illinois Department of Public Health (“IPDH”) and the Winnebago County Health Department as described in the consent document.

Consent Document
https://drive.google.com/drive/folders/0Bwyo_6LygAXnc1BiRzJ5T2N0a1k?resourcekey=0--BOEwnuBHFaIt7fKeMSM3g

The consent form can be found in the folder linked above and can be printed, signed and returned OR you can provide consent by filling out this electronic form which will serve as your electronic authorization providing consent for your child to obtain a COVID-19 Rapid Antigen Test performed by trained school personnel.
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Email *
School *
Required
Student Name *
Teacher/Homeroom Name
Parent/Guardian Name Authorizing Consent *
Parent/Guardian email *
Parent/Guardian phone number: *
As parent/guardian of the student named above, I consent to allow the District to complete the BinaxNOW test on my student as outlined above. I further authorize the District to share my student’s identifying information and the results of the BinaxNOW test in the manner described in the consent form. I have read, understand, and agree to the terms herein, including the Acknowledgment of Risk and Waiver of Liability. This COVID-19 Voluntary Testing Consent & Acknowledgment Form is effective upon signature and will be valid through June 30, 2022, unless revoked by providing written notice to Dr. Catherine Wang. *
Required
A copy of your responses will be emailed to the address you provided.
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