Maine PreK to 12 School COVID-19 Rapid Test (BinaxNOW)Parent/Guardian Consent Form: School Year 2021-2022
RSU57 seeks to maintain a safe environment for employees, students, their families, and the community. This consent form provides RSU57 or its designee with your permission to perform a COVID-19 screening test for your child at the school or its designated site.

By signing below, you are indicating that you voluntarily consent to this screening procedure for the detection of COVID-19 for your child. Please read the attached information accompanying this form regarding school-based testing.

COVID-19 Test Information Statement

For Rapid BinaxNOW Ag Testing:
The test may be collected by self-swab or by a school nurse. The test involves a nasal swab that is used to determine the potential presence of COVID-19. The specimen collected for a rapid test will have results in approximately 15-20 minutes. The school will share the results with the CDC for public health reporting. The school or its designee will communicate those results to you following the test. Additionally, the school or its designee will request that the parent will contact the Primary Care Provider to ensure coordination of care, should the result be positive.

Sign in to Google to save your progress. Learn more
Email *
Parent First Name *
Parent Last Name *
Parent Phone Number *
Address (Street, City, State, Zip Code) *
Student First Name: *
Student Last Name: *
Student Middle Initial *
My student's date of birth *
MM
/
DD
/
YYYY
My child attends the following school *
My child is in grade *
Homeroom Teacher Name (for high school students, please list school counselor name) *
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of RSU57.

Does this form look suspicious? Report

Google Forms