Parent/Guardian First and Last Name
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Parent/Guardian Cell/Mobile #

Parent/Guardian Email Address

Child/Student First and Last Name
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School ID #- LIVINGSTON ISD (Please leave blank)
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Driver's License # (if applicable) or State ID #

Address
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City
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State / Province / Region
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Zipcode Min: 1 Max: 5
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Country

School/Campus

Student Grade Level

Student Date of Birth

Student's Age

Race/Ethnicity (Choose only One)

Gender ( Choose only One)

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
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Date

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