BinaxNOW Testing Consent
By completing the below information you consent and agree to the following:

Pearl City School District #200 is authorized to conduct an antigen based COVID-19 Abbott Labs BinaxNOW test on the listed student or staff member during the 2021-2022 school year.

I authorize Pearl City School District #200 to supply copies of these records to Stephenson County Health Department, Illinois Department of Public Health and Primary Care Provider's office, as needed.

I understand that this record will be entered into the record systems at school and with the Illinois Department of Public Health.

I understand follow-up testing may be required as determined by Local and State Guidelines, or that BinaxNOW Testing may not be applicable in all cases, as determined by Pearl City School District #200 and Stephenson County Health Department personnel.

By completing the form and typing your name below, you are signing this document electronically. You agree your electronic signature is the legal equivalent of your manual signature on this document.

Complete one form per student please.
Email *
Student/Staff Name *
Student/Staff Member Date of Birth (MM/DD/YYYY) *
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Age *
Street Address *
Phone Number *
Email Address *
Primary Care Provider or Physician's Name *
Who is completing this form? *
Typed Signature of Parent, Guardian or Self (if over 18 years old) *
Today's Date (MM/DD/YYYY) *
MM
/
DD
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YYYY
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