Student COVID-19 Consent Form Jan 2021

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Please complete a form for each of your children. This is to give your consent for them to take part in lateral flow testing at St Michael's Catholic College. Please note if your child is 16 or over they will need to complete this form themselves.

Email *

Student's First Name *

Student's Surname *

Student's Year group *

Year 7

Year 8

Year 9

Year 10

Year 11

Year 12

Year 13

Student's Date of Birth *

YYYY

Student's Gender (this information is needed for DHSC research purposes) *

Female

Male

Prefer not to say

Other:

Student's Ethnicity (this information is needed for DHSC research purposes) *

Asian or Asian British

Black, African, Black British or Caribbean

Latin/South American

Mixed or multiple ethnic groups

White

Prefer not to say

Other:

Student currently showing any COVID-19 symptoms? *

Yes

Home Postcode *

Email Address (this is where the results will be sent) *

Mobile Number (this is where the results will be sent - MOBILE NUMBER ONLY) *

Name of Parent/Guardian giving consent . If you are a student aged 16 or over and providing your own consent, please answer with not applicable. *

What is your relationship to the student? *

Mother

Father

Guardian

Grandparent

Relative over 18 years old

Other:

I have read and understood all of the terms of consent *

Yes

Signature (please type full name below) *

Please prove details of any health or accessibility issues which might affect a child’s safe participation in the testing exercise.

A copy of your responses will be emailed to the address you provided.

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