Parent Consent form for Proximal Testing and Surveillance Testing for COVID-19

Instructions: Please complete and submit this form to opt in to the Erie County Department of Health (ECDOH) Proximal and Surveillance Testing for COVID-19 for students and staff. Items with * are required fields. Any information you provide is confidential. An ECDOH employee will contact you with additional information and instructions.

Student/Staff First Name

Student/Staff Middle Initial

Student/Staff Last Name

Date of Birth of Student/Staff

Phone Number

Email Address

Confirm email

Student/Staff Grade

School District Student/Staff is in

School Student/Staff Attends

Type of test you are consenting to (check all that apply)

Surveillance Testing

Proximal Testing

Parent/Guardian/Staff Full Legal Name (first name, middle initial, last name)

Electronic Signature Agreement

By checking the this box, you agree and acknowledge that you are the legal parent/guardian of this student or school staff and give your consent for him/her/yourself to participate in this program and you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature.

Acknowledgement

After clicking submit you will be directed to Quadrant Biosciences website to fill out their consent form. You must complete that form in addition to the form above in order to be enrolled in the ECDOH Proximal Testing and/or Surveillance Testing for COVID-19 Program. Do you understand this requirement?