Student COVID-19 Testing Consent Form

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On September 2, 2021, the New York Department of Health (“NYDOH”) issued a Commissioner's Determination on COVID-19 requiring school districts to offer COVID screenings for students. As per the determination, schools must:

Offer screening testing for students (obtain parent or guardian consent for minors, and where otherwise required pursuant to school policy): P-12 schools are required to offer screening testing to unvaccinated students on a weekly basis in geographic areas identified by the CDC as having moderate, substantial, or high transmission rates.

The District will be utilizing the Abbott BinaxNOW COVID-19 Rapid Antigen Test and using trained personnel to collect samples. This test uses a shallow Nasal Swab (front/sides of nose) for sample collection. Participation in testing is not required for attendance for in-person instruction. This is a voluntary program offered to interested families .

If you are interested in weekly COVID-19 screening, please take a moment to complete this form to provide consent for the above-referenced COVID- testing to occur:

TO BE COMPLETED BY PARENT/GUARDIAN
Student FIRST Name
Student LAST Name
Date of Birth	Jan. Feb. Mar. Apr. May Jun. Jul. Aug. Sep. Oct. Nov. Dec.     01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31     2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021
Gender	Male Female
Address
Household Phone
Grade	PreK Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade 8th Grade 9th Grade 10th Grade 11th Grade 12th Grade Other
School	Gardnertown GAMS Tech Horizons-on-the-Hudson Meadow Hill New Windsor Temple Hill Vails Gate Heritage MS South MS NFA Main Campus NFA North Campus NFA West Campus
Student ID (if known)
Consent: I consent to disclosure of the results of the testing to the Newburgh Enlarged City School District (where applicable). Additionally I will receive communication if my child tests positive for COVID-19 with information on medical follow up as per NYSDOH guidelines I understand that the test results and other info may be disclosed as required/permitted by law to the State and/or local health departments. I confirm that I have read all the information and confirm my choices above. Yes, by completing this form I give my permission to collect a sample from my child and conduct a weekly screening for COVID-19.
Parent/Guardian Name
Parent/Guardian Phone
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