Consent to Test a Minor

Minor Student's Name*

First

Last

Minor Student's Date of Birth*

Minor Student's Grade*

Minor Student's Address*

Street Address

Address Line 2

City

State

ZIP Code

CONSENT*

I give consent for my minor child/legal dependent to have a test sample taken for COVID-19.

I authorize that a test sample may be taken for COVID-19 by ATC Healthcare and/or its affiliates or The Waldorf School of Garden City for surveillance testing or wellness checks. I do hereby consent to any physician or health care provider or authorized provider examining or testing my minor child to use or disclose protected health information for reporting purposes.

Which test are you giving consent for?*

Regular Weekly Testing
Nurse/Wellness Testing
Specific Event Testing (i.e. Glen Brook Trips)

select all that apply

Parent or Guardian Name*

First

Last

Preferred Parent/Guardian Phone*

Authority

I have the legal authority to consent to this test administration for the child named above.

I have the legal authority, based on the relationship to the child as indicated below pursuant to New York Public Health Law § 2504, to consent to this test administration for the child named above.

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