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.
Email address *
Full Name *
How are you connected to IDEA PCS?
Date of Birth *
MM
/
DD
/
YYYY
Address *
Telephone Number *
Gender *
Race *
I am registering for the following COVID Testing Date (check all that apply) *
Required
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