COVID-19 BinaxNOW Antigen Testing Consent Form
You or your child may be eligible to receive a nasal swab BinaxNOW antigen test if you or your child is showing symptoms of COVID-19. Symptoms may include : cough, fever, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, vomiting or diarrhea. If you agree to to allow yourself or your child receive the BinaxNOW antigen test if symptoms of COVID-19 are present any time while on campus for the duration of this consent, please complete the following information.
Email *
Name of Individual Being Tested (first and last name) *
Is the individual being tested a VSD student or staff member? *
Required
Date of Birth *
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DD
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YYYY
Parent/Guardian Name (if not applicable type N/A) *
School Attended/Worked At (if not staff/student, type N/A) *
Grade Level (if not applicable type N/A) *
Phone Number *
Would you like us to text you with test results to the phone number listed above? *
Required
Address *
I authorize Vail School District trained personnel to administer the COVID-19 BinaxNOW antigen test *
Required
I understand that all tests results will be disclosed to county and state health officials and designated school officials. *
Required
If myself or my child has symptoms, I have been informed that a negative test will not necessarily rule out infection or COVID-19 and I or my child will still be required to follow Vail School District procedures for symptoms consistent with COVID-19. *
Required
Waiver of Liability and Release of Claims : In providing my consent for the District to administer the BinaxNOW antigen test to myself or my child, and to the fullest extent permitted by the law, I hereby agree to waive, release, and discharge any and all claims, causes of action, damages, and rights of any kind against the District, its insurers, the District's Governing Board, and all of their respective employees, agents, representatives, and volunteers(the "Released Parties") arising from or relating in any way to the damage, injury, trauma, illness, loss, disability, or death that may occur to my child, me or my household members as a result of the test administration or a false negative/false positive test result from the District's administration of the COVID-19 BinaxNOW antigen test to my child. I further agree not to sue the Release Parties, and to defend and indemnify the Release Parties for all claims, damages, losses, or expenses, including attorney's fees, if a lawsuit if filed concerning an injury, illness, or death to me, my child, or my household members as a result of the test administration or a false negative/positive test result from the District's administration of the COVID-19 BinaxNOW antigen test given to either myself or my chid. By checking Yes below, I agree to the Administration of the COVID-19 BinaxNOW antigen test by District personnel to be provided to myself or my child. *
Required
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