COVID-19 Test To Stay and Learn Consent
In an effort to keep asymptomatic, close-contact students in school, COVID-19 antigen testing can take the place of quarantine and your child may remain in-person learning. Please complete one form for each student in your household.

Please carefully read and provide written acknowledgment of the following informed consent:

a. I authorize a COVID-19 testing administrator associated with the school district, local health
department or state health department to conduct collection and testing for COVID-19 through
a nasal swab collection as ordered by an authorized medical provider or public health official.
b. I authorize my test result, or the test result of my child if my child is under the age of 18
years, to be disclosed to the county, state, or to any other governmental entity as may be
required by law.
c. I understand that, as with any medical test, there is the potential for a false positive or false
negative COVID-19 test result.
d. I give permission for the Northeast Kansas Multi-County Health Department and USD 415 to
contact me using non-secure methods (e-mail) regarding this COVID-19 test result, and I
understand the risks involved.
Does USD 415 have your permission to test your student? *
First Name of Student *
Last Name of Student *
Grade *
Parent/Guardian First and Last Name *
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