ATS BINAXNOW CONSENT Posted 3:41 PM by Amber Woods Contact InformationParent/guardian of child being testedName(Required) First Last Address(Required) Street Address City State ZIP / Postal Code Phone(Required)Email(Required) Best way to contact you(Required) Phone Call Email Demographic Information about the Student Being TestedDemographic information is needed to comply with Arizona Department of Health Services and Pima County Health Department reporting requirements.Student's Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Gender(Required) Male Female Other Race(Required) American Indian or Alaskan Native Asian Black, or African American, or Black African White Native Hawaiian or Other Pacific Islander Other Your ConsentI consent to the administration of a Rapid COVID-19 Antigen Test by Sahuarita Unified School District for my child named above. I certify each of the following: Consent(Required) I have signed this form freely and voluntarily, and I am legally authorized to make decisions for my child named above.(Required)Consent(Required) I authorize trained staff using a Rapid COVID-19 Antigen Card to test my child named above for COVID-19 infection.(Required)Consent(Required) I understand that there is the potential for false positive and false negative COVID-19 test results. I have been informed that a negative test result will not necessarily rule out infection and I am still required to follow Sahuarita Unified School District's instructions to prevent the spread of COVID-19.(Required)Consent(Required) I agree that I will follow the public health recommendations regarding the need for my child’s isolation or quarantine following testing.(Required)Consent(Required) I understand that Sahuarita Unified School District is not acting as my or my child’s medical provider and does not replace treatment by my or my child’s medical provider. I agree I will seek medical advice, care, and treatment from my medical provider if I have questions or concerns or if my or my child’s condition worsens.(Required)Consent(Required) I understand that all test results and required personal information will be disclosed as permitted by law to the Arizona Department of Health Services, the Pima County Health Department, their contracted services providers, and designated members of the Sahuarita Unified School District contact tracing team.(Required)Consent(Required) I acknowledge that I have received information about the rapid COVID-19 antigen card and/or can obtain a Fact Sheet about the test.(Required)Consent(Required) I understand that this consent form will be valid until May 25, 2023 unless I choose to revoke my consent. I can revoke my consent by notifying the school health office in writing that I choose to revoke my consent.(Required)Signature(Required)By signing, I acknowledge that I understand and agree to all statements checked above.Parent/Guardian Name(Required) First Last Δ
