Student Information For Covid 19 Testing
This form must be filled out prior to testing. Please fill out this entire form. When you are done, make sure you type in your name and date for your digital signature. MAKE SURE YOU BRING YOUR STUDENT ID THE DAY OF THE TESTING
Email address *
First Name *
Middle Name
Last Name *
Street Address *
Unit #
City *
State *
Zip Code
Phone *
Email *
Date Of Birth *
Birth Gender *
Ethnicity *
Race *
Are you currently experiencing Any of the following symptoms (check all that apply) *
Consent for Testing: I understand that Governor Herbert signed Executive Order 2020-73 on 8 November 2020. It requires each participant including each coach, trainer, staff member, and athlete, to wear a face mask, except while actively performing as an athlete AND to submit to and receive a negative test result from a diagnostic test to determine current COVID-19. The results of the test will be released to the Southwest Utah Public Health Department. My parent(s) and/or legal guardian(s), are aware of and consent to this requirement. If I refuse to comply with this requirement or if I tamper with the test or try to cheat the testing results, I understand that I will not be allowed to participate in the activity. TYPE YOUR NAME BELOW AS YOUR DIGITAL SIGNATURE *
Assigned testing date (for this week) *
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