Germantown Hills School District #69 BinaxNOW COVID-19 Testing Consent Form
Please complete a permission form FOR EACH child who attends Germantown Hills School District #69. Consent may be revoked at any time by contacting Superintendent Dan Mair.
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I authorize Germantown Hills School District #69 to conduct the collection and testing for COVID-19 on my student through a nasal swab. The BinaxNOW test is a fast acting antigen test administered by our school nurse with results available within 15 minutes. The school nurse will communicate the test results once they are available.

If you consent to COVID-19 rapid testing, you authorize and acknowledge the following:

• I authorize my student’s test results to be disclosed to the county, state, or to any other governmental entity as may be required by law.

• I acknowledge that a positive test result is an indication that my student must self-isolate for at least 10 days according to the requirements outlined by the Illinois Department of Health

• I acknowledge that if my student’s test results come back positive, siblings and/or family members that attend Germantown Hills School District #69 will also be asked to quarantine at the same time if unvaccinated. The school nurse will be in communication about a return date for these individuals and information about testing to stay.

• I understand that if my student receives a positive rapid test, the positive result will be considered a “positive” and my student is recommended to follow up with their health care provider.

• I acknowledge that my student may be asked to go home if they are symptomatic even if their COVID-19 test results are negative. Students are expected to stay home when they are ill.

• I understand that the school nurse and testing does not replace treatment by my student’s health provider, and I assume complete and full responsibility to take appropriate action with regard to my student’s test results.

• I understand that, as with any medical test, there is the potential for a false positive or false negative COVID-19 test result.

• By signing this Rapid Testing Consent & Acknowledgement, I (Parent/Guardian and Student), on my own behalf and on behalf of Student, agree to waive, release, indemnify, hold harmless, and covenant not to take legal action against Germantown Hills School District #69, its Board of Education, administrators, employees, agents, representatives, volunteers, insurers, assigns, and successors, with respect to any and all claims, charges, and causes of action, whether known or unknown, past, present, or future, including, but not limited to, any and all costs, expenses, and attorneys’ fees, by reason of any injury, illness, death, damage, or loss, arising out of or in connection with Germantown Hills School District #69’s administration of the BinaxNOW test to Student and/or with respect to and related to Germantown Hills School District #69’s sharing of Student’s test results.

This consent and authorization is effective upon electronic signature and will be valid through June 30, 2022, unless revoked in writing. Any revocation must be sent to Superintendent Dan Mair at, or it may be delivered to the District Office.

I have been informed about the test purpose, procedures, and possible benefits and risks. I have been given the opportunity to ask questions, and I understand that I can ask additional questions at any time.

Parent/Guardian's Last Name *
Parent/Guardian's First Name *
Child's Last Name *
Child's First Name *
Child's Grade *
In the event that my child is identified as a close contact to a positive COVID-19 case, I give consent for my child to be tested by Germantown Hills School District #69 for COVID-19 using the BinaxNOW test. *
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