Registration Form

1

A parent or a guardian must enroll the student and provide consent in order to participate in the program. Have your enrollment forms been signed?* This field is required.

YESNO

2

Great, now that you're enrolled, let's get started:
1. Fill out this form with the information on the person being tested
2. Write clearly - full last name and first name (no nicknames) and DOB on the tube (MM/DD/YYYY).
3. For saliva: Spit in the tube, discard funnel, and close the cap tightly
4. For nasal swab: Swab each nostril, place the swab inside the tube, break the handle at the mark and close the cap tightly.

3

Please click submit to enroll now.

4

Name* This field is required.

First Name

Last Name

5

DOB* This field is required.

Date

6

Barcode

7

Barcode* This field is required.Enter characters found below the barcode on the collection tube:

Barcode format: Z000000

8

sid

9

Browser info

10

DOB* This field is required.

11

Unique ID

12

barcode_tmp

13

show_barcode

14

Barcode* This field is required.Enter characters found below the barcode on the collection tube:

Barcode format: Z000000