Levittown School District- Consent for Covid-19 Testing
In the event that the Levittown School District is identified as part of a micro-cluster in the Yellow, Orange or Red Zones, your child may be required to be tested for Covid-19. For more information on the New York State Micro-Cluster Strategy or other Covid-19 related issues, please visit
PLEASE COMPLETE A SEPARATE FORM FOR EACH SCHOOL-AGED CHILD IN YOUR HOUSEHOLD.
Is your child REMOTE only?
Student Last Name
Student First Name
Abbey Lane Elementary
East Broadway Elementary
Gardiners Avenue Elementary
Lee Road Elementary
Summit Lane Elementary
Jonas Salk Middle School
Wisdom Lane Middle School
Division Ave. HS
Parent/Guardian Name (Last, First)
Parent/Guardian Telephone Number (mobile preferred)
Parent/Guardian Email Address (This address will be used to notify a parent/guardian of an upcoming test.)
Consent: By clicking below, I attest that: 1) I am legally authorized to give consent for the child named above. 2) I freely and voluntarily consent to have my child tested for the Covid-19 virus by a school nurse. 3) I understand that my child may be tested multiple times through June 25, 2021 and that those tests may occur on days scheduled by the Levittown School District in accordance with state and county mandates. 4) I understand that this consent will be valid through June 25, 2021, unless I notify an administrator in my child's school in writing that I revoke my consent. 5) I understand that my child's test results and other information may be disclosed as permitted by law.
I agree to the statements above.
I do not agree to the statements above.
I am willing to take my child to our family Health Care Provider or Urgent Care for Covid-19 testing, during the testing period, and agree to submit proof of results when requested.
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This form was created inside of Levittown Public Schools.