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:
Student FIRST Name
Student LAST Name
Date of Birth      
Household Phone
Student ID (if known)
  • 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
Please sign your name below. You can use your mouse or, if using a touch screen, your finger.