COVID-19 SYMPTOMATIC TESTING AUTHORIZATION FORM 2022-2023
Ashburnham-Westminster Regional School District
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Student's Last Name *
Student's First Name *
Student DOB *
Student Address *
Student Race (please answer N/A if prefer not to answer) *
Ethnicity (please answer N/A if prefer not to answer) *
Gender (please answer N/A if prefer not to answer) *
Student's School *
By checking yes, I authorize my child to utilize Ashburnham-Westminster Regional School District's Symptomatic COVID-19 Testing for when they present with symptoms while at school at the discretion of the school nurse.  I understand that the nurse will notify me of any positive results, and that all positive results will be reported to the Department of Public Health per state regulations.  Shallow nasal swab samples are collected at school by a school nurse using an approved diagnostic test. *
Required
Legal Guardian Name (1st) *
Legal Guardian Phone Number (1st) *
Legal Guardian Email (1st)
Legal Guardian Name (2nd)
Legal Guardian Phone Number (2nd)
Legal Guardian Email (2nd)
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