CLEVELAND HILL UNION FREE SCHOOL DISTRICT STUDENT COVID-19 TESTING CONSENT FORM
The State of New York has determined that the District is located within a “Yellow Zone,” as defined by the New York State Cluster Action Initiative, which requires weekly testing of students and staff due to elevated rates of COVID-19 transmission in the area. As a result, the District is required to test 20% of in-person students, at least once a week, for as long as the District remains in a Yellow Zone (or until the State modifies or lifts the zone requirements).
In order to test your child or children, we need your consent. Students will be selected on a random basis each week, so if your child is selected one week, they may or may not be tested the following week. All testing will be performed through the New York State Department of Health (“DOH”).
If tested, some information about your child must be shared with the DOH and contracted service providers for COVID-19 Testing, including your child’s name and COVID-19 test results and any other data required by the Commissioner of Health. This information will be shared with the DOH for public health purposes, such as contact tracing. If any member of the school community tests positive during this process, the District will continue to follow the guidelines as outlined within the DOH and New York State Education Department reopening guidance.
By submitting the form below, I attest that:
• I have submitted this form freely and voluntarily, and I am legally authorized to make decisions for the child named above.
• I consent for my child to be tested for COVID-19 infection.
• I understand that my child may be tested multiple times.
• I understand that this consent form will be valid through June 30, 2021, unless I notify the District in writing that I revoke my consent.
• I understand that if I revoke my consent or refuse to submit this form, my child may be required to continue their education via remote learning.
• I understand that my child’s test results and other information may be disclosed as permitted by law.
• I understand that if I am a student age 18 or older, or may otherwise legally consent for my own health care, references to “my child” refer to me and I may submit this form on my own behalf.
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Please select the appropriate response below (the response direct you to the appropriate section of the form):
I will permit ALL of my children who attend Cleveland Hill to be randomly tested, if selected.
I do NOT want ANY of my children randomly tested, if selected.
I will permit SOME of my children who attend Cleveland Hill to be tested, while denying testing for others
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