Pooled Covid-19 Testing Consent Form
Parent/Guardian Name *
Parent/Guardian Cell/Mobile # *
Parent/Guardian Email Address *
Student First Name *
Student Last Name *
Address Line 1 *
Address Line 2
City *
ZipCode *
Student Date of Birth *
(YYYY-MM-DD)
Gender *
Race *
Ethnicity *
Student ID # *
This is your child's LASID or Lunch Number, a 6-digit number beginning with 2, ex: 293456, used to log onto computers.
School *
Grade Level *
Homeroom
(if applicable)
Has the student listed above been diagnosed with COVID-19 in the past 90 days?: *
Consent *
Signing Name of Parent/Guardian *
Please type your name.
Submit
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