RE-1 Valley School District BinaxNOW ONE TIME RAPID TEST CONSENT

RELEASE OF INFORMATION AND INFORMED CONSENT TO COVID-19 TESTING. *This form must be signed prior to specimen collection*
Name: *
Student: School Attending and Grade *
Non-Student:
DOB: *
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Address: (include City, State and Zip) *
Phone Number: *
please carefully read each statement and check each box: *
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**The electronic completion of this box is considered an official signature.** Signature and date: *
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