Consent Form for COVID-19 Point of Care During 2022-23 School Year
Greenville Central School is seeking your consent for point of care testing during the 2022-23 school year.
Only students whose parents or guardians consent to testing will be tested. The school will conduct point of care testing only if your child becomes symptomatic while at school.

If you consent, your child will receive a free diagnostic test for the COVID-19 virus. Collecting a specimen for testing involves inserting a small swab, similar to a Q-Tip, into the front of the nose. 

Test results will be available to school staff within 15 minutes of collection. You will only be contacted if your child is positive. If your child’s test results are positive, your child will be sent to the isolation room in the nurse’s office while they wait for you to pick them up to go home and begin isolating per the Department of Health.  Please follow your local health department’s requirement for isolation. If your child’s test results are negative, this means that the virus was not detected in your child’s specimen. If your child tests negative; but has symptoms of COVID-19, you may be asked for a differential diagnosis from your child’s doctor. If you have concerns about your child’s COVID symptoms or an exposure to COVID-19, you should call your local health department and your child’s doctor.

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Parent/Guardian Last Name *
Parent/Guardian First Name *
Parent/Guardian Address *
Parent/Guardian Phone/Cell *
Parent/Guardian Email Address *
Best way to contact you? *
Child's Last Name *
Child's First Name *
Child's Date of Birth (Quick tip:  click on the calendar to change the month and year) *
Child's School *
Child's Home  Address *
Notification of Information Sharing
The law allows some information about your child to be shared with and among certain County and New York State agencies and their contracted service providers, including those listed below. This information will be shared only for public health purposes. Information about your child that may be shared with these agencies and service providers conducting COVID-19 testing includes your child’s name and COVID-19 test results, date of birth/age, gender, race/ethnicity, school name(s), teacher(s), cohort/pod, enrollment and attendance history, and program participation, names of other family members or guardians, address, telephone, mobile number, and email address. Sharing of information about your child will only be done in accordance with applicable law and policies protecting privacy and the security of your child’s data.
By digitally signing below, I attest that:

I have signed this form freely and voluntarily, and I am legally authorized to make decisions for the child named above.
   -I consent for my child to be tested for COVID-19 infection based on consent below.
   -I understand that my child may be tested multiple times during the 2022-23 school year.
   -I understand that my child’s test results, and other information may be disclosed as permitted by law.

I consent to the following testing for my child *
Point of care testing
Signature of Parent/Guardian (if child is under age 18) *
Thank you.  Please submit a Consent Form for each child.
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