COVID Test Consent Form

COVID-19 Test Consent Form
Full Name of person to be tested*
PrimaryElementaryIntermediateJunior HighHigh SchoolOther
Date of Birth

MonthDayYear
Date
Age
AsianBlackHispanicWhiteNative American/IndigenousUnknown
MaleFemale
YesNo
When did the symptoms start?

MonthDayYear
Date
YesNoUnknownPrefer not to answer
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Name (for students under 18)
By signing below, I attest that:
1. I authorize Pittsburg ISD to conduct collection and testing on myself or on my child under 18 years of age for COVID-19 by nasal swab.
2. I acknowledge that a positive test results is an indication that my child/myself must self-isolate in an effort to avoid infecting others.
3. I understand Pittsburg ISD is not acting as my or my child's medical provider, this testing does not replace treatment by my or my child's medical provider, and I assume complete and full responsibility to take appropriate action with regards to my or my child's test results. I agree I will seek medical advice, care and treatment from my or my child's medical provider if I have questions or concerns, or if their condition worsens.
4. I understand that, as with any medical test, there is the potential for a false positive or a false negative COVID-19 test result.
Pittsburg ISD uses FDA approved tests provided by the federal government. We will only test with your consent.

Please understand that neither the test admnistrator nor Pittsburg ISD nor any of its trustees, officers, employees, or organization sponsors are liable for any accident or injuries that may occur to your child or yourself (if student age 18 or older), as a result of agreeing to the test.
Signature
Today's Date:

MonthDayYear
Date
Should be Empty:

COVID-19 Test Consent Form