Elaine Ellis- Patient Demographics Form-COVID-19 Testing- January 2021
Elaine Ellis Center of Health (EECH) will be providing COVID-19 testing at IDEA PUBLIC CHARTER SCHOOL for staff and IDEA families. If you wish to participate, please complete the following information. *One Google form per person.
* Required
Email address
*
Your email
Full Name
*
Your answer
How are you connected to IDEA PCS?
IDEA Student/Family Member
IDEA Staff Member/Family Member
Date of Birth
*
MM
/
DD
/
YYYY
Address
*
Your answer
Telephone Number
*
Your answer
Gender
*
Female
Male
Race
*
Your answer
I am registering for the following COVID Testing Date (check all that apply)
*
COVID-19 Testing- Thursday, January 28th 9:30 am- 10:30 am @ IDEA
Required
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