COVID-19 Student Consent and Waiver
Wilmette School District No. 39 is offering a program to perform a non-diagnostic COVID-19 “RT-LAMP” assay screening (“Screening”) as part of the District’s efforts to maintain a safe environment for our school community. This Screening is being used as one part of the District’s overall safety protocols that includes masks, social distancing, cleaning, and other mitigation strategies.

In order to perform this non-invasive Screening, the student being screened will deposit a small amount of saliva in a sterile container at home. The container should then be wiped clean, placed in a sealable plastic bag, and returned to the District with the student where it will be collected. The saliva will then be screened for the presence of COVID-19. Saliva samples will be used solely for the purpose of performing the Screening and then destroyed following screening in a manner appropriate for biological specimens. Individual results of the screening will not be published under any circumstances.

In the event the Screening indicates a potential presence of COVID-19, the individual will be notified of “findings of potential clinical significance.” Parents will not be contacted if the student receives a negative result.

Because of the ongoing public health crisis, the District will treat findings of potential clinical significance using this screening tool the same way that the District will treat the outcomes of other screening measures it is using, such as symptom screening, temperature measurements, and observable COVID-19 like symptoms.

Thus, if the screener indicates there is a potential presence of COVID-19, the individual will be required to stay home from school and self-isolate until cleared through an FDA approved diagnostic test or otherwise complied with IDPH guidance on required quarantine and return to work/school protocols.

By entering information below and submitting it to the District, you:

1) voluntarily consent for your child to participate in the non-diagnostic detection of a clinically significant finding that could indicate the presence of COVID-19; and

2) voluntarily consent for your child to participate in the collection of saliva for the sole purpose of running this program; and

3) understand and consent to District employees or volunteers distributing Screening kits to you or your student at school or at your home; and

4) voluntarily consent to the disclosure of findings of clinical significance to the District Nurse’s office which will be maintained as a student or medical record in the same manner that the District currently maintains other student or medical records such as immunizations and physicals; and

5) acknowledge that the results of the Screening should not be used as the sole basis, or any definitive basis, to diagnose or confirm COVID 19 or inform infection status and that no surveillance is 100% accurate; and

6) acknowledge that you release, promise not to sue, hold harmless, and indemnify the District from any claims (including legal costs) arising out of the participation in the Screening, brought by the student or a third person, including but not limited to any inaccurate Screening results.

If at any time you choose to revoke consent as provided here, the District must receive revocation in writing indicating your desire to revoke your consent for you or your child to participate in the administration of the Screening as detailed here.

If you have any questions about the Screening, please contact Kristin Swanson (; 847-512-6004) at the District or feel free to discuss the proposed screening with your physician.

Please complete a separate form for each child.
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PLEASE NOTE: Registration for this week of SafeGuard Screening has closed. You are now registering to participate in screening beginning April 5th. If you have already registered as a participant in this program, there is no need for you to resubmit registration.
Your child's testing supplies will be sent home from school.
Student Legal First Name *
Student Legal Last Name *
Student ID *
School *
Grade Level *
Homeroom Teacher *
Parent Name (typing your name below constitutes your signature) *
Date *
The District is providing this Screening program for free to students attending in-person schooling. The direct costs of the program is $11 per test. If you would like to contribute the direct costs of your child's participation in this program, please indicate so below. By indicating yes, we will contact you through email after the sign-up window with directions on how to make a payment. *
By completing the registration form now, you are registering your child to participate in screening beginning April 5th. Your child's testing supplies will be sent home with them from school.
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A copy of your responses will be emailed to the address you provided.
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