COVID-19 Parent Permission Form

Please complete the COVID-19 Parent Permission Form below. Required fields marked with an asterisk *

Parent/Guardian First and Last Name*

Answer required for "Parent/Guardian First and Last Name"

Parent/Guardian Cell/Mobile #*

Number Required

Parent/Guardian Email Address*

Answer required for "Parent/Guardian Email Address"

Child/Student Information

Child/Student First and Last Name*

Answer required for "Child/Student First and Last Name"

School ID#-Santa Gertrudis ISD (Please Leave Blank)

Answer required for "School ID#-Santa Gertrudis ISD (Please Leave Blank)"

Address

Street Address*

Answer required for "Street Address"

City*

Answer required for "City"

Zip/Postal*

Answer required for "Zip/Postal"

School/Campus*

Answer required for "School/Campus"

Academy High School

Santa Gertrudis School

Student Grade Level*

Answer required for "Student Grade Level"

Student Date of Birth*

Answer required for "Student Date of Birth"

Student's Age*

Answer required for "Student's Age"

Race/Ethnicity (Choose Only One)*

Answer required for "Race/Ethnicity (Choose Only One)"

Asian

Black

Hispanic

White

Native American/Indigenous

Unknown

Gender (Choose only One)*

Answer required for "Gender (Choose only One)"

Male

Female

Reaquired field:By signing below, I attest that: A) I authorize the school system to conduct collection and testing of my child or me (if student age 18 or older) for COVID-19 by nasal swab. B) I acknowledge that a positive test result is an indication that my child or me (if student age 18 or older), must self-isolate and also continue wearing a mask or face covering as directed in an effort to avoid infecting others. C) I understand the school system is not acting as my child’s medical provider, this testing does not replace treatment by my child‘s medical provider, and I assume complete and full responsibility to take appropriate action with regards to my child’s test results. I agree I will seek medical advice, care and treatment from my child’s medical provider if I have questions or concerns, or if their condition worsens. D) I understand that, as with any medical test, there is the potential for a false positive or false negative COVID-19 test result. I, the undersigned, have been informed about the test purpose, procedures, possible benefits and risks, and I have received a copy of this Informed Consent. I have been given the opportunity to ask questions before I sign, and I have been told that I can ask additional questions at any time. I voluntarily agree to this testing for COVID-19.

Parent Signature*

Answer required for "Parent Signature"

Date*

Answer required for "Date"

Signature of Student (if age is 18 or over or otherwise authorized to consent)*

Answer required for "Signature of Student (if age is 18 or over or otherwise authorized to consent)"

Please fix the highlighted areas below before submitting.

COVID-19 Parent Permission Form