Syracuse Academy - Diagnostic Testing Consent Form

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This information, once completed and submitted, will grant permission for symptomatic COVID-19 testing for the named minor. Should you want to print the form and submit a hard copy, please call your local school. Parents will need to complete this consent survey for each of their school aged children. Even though you are providing your parental consent for our nurses to test your child when he or she has COVID-19 symptoms, the school will contact you to inform you that your child is exhibiting COVID-19 symptoms and since you provided the District with permission to test your child, you will still have the choice of our nurse testing your child or you can come pick up your child and bring your child to a testing facility if that is what you prefer.

Email *

Student First Name *

Student Last Name *

Grade that your child attends *

Parent/Guardian First Name: *

Parent/Guardian Last Name: *

Parent/Guardian Phone Number: *

1. I authorize the collection and testing for COVID-19 through use of a BinaxNOW COVID-19 Antigen Test for my child(ren) only when my child is exhibiting COVID-19 symptoms. 2. I understand that I will be informed of my test results by the Syracuse Academy of Science Charter School or the Department of Health. 3. By voluntarily agreeing to this testing, I understand that my test results will be disclosed to the county, state, or any other government entity as may be required and/or permitted by law, and that the test results will be reported to the Syracuse Academy of Science Charter School. 4. I acknowledge that a positive test result means I must isolate my child(ren) in an effort to avoid infecting others. 5. I understand the Syracuse Academy of Science Charter School staff members (nurses) who are collecting specimens and providing test results, are not acting as my or my child(ren)’s medical provider and this specimen collection and testing does not replace treatment by a medical provider. I assume complete and full responsibility to take appropriate action with regard to my, or my child(ren)’s, test results. I agree I will seek medical advice, care, and treatment from a medical provider if I have questions or concerns, or if my, or my child(ren)’s condition worsens. 6. I understand that, as with any medical test, there is the potential for false positive or false negative test results. *

ACCEPT: By clicking this acceptance and submitting my responses on this form, I, as the named parent/guardian, have been informed about the test purposes, possible benefits and risks, and I have received a copy of this informed consent. I have been given the opportunity to ask questions before I sign, and I have been told that I can ask other questions at any time. I voluntarily agree to testing for COVID-19 for myself and/or my child(ren) listed above.

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A copy of your responses will be emailed to the address you provided.

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