Request for COVID Rapid Antigen Test
Please complete the following information to receive one COVID test for each child who attends our school. This offer is only available while supplies last.
I would like to receive one test kit for each child listed below:
| Child’s Last Name | Child’s First Name | Date of Birth | Grade Level | Homeroom Teacher |
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Please choose one of the following methods for receiving your tests:
________ I will come to school during regular school hours on the following date to pick up my tests. Date of pick up: _____________
________ Please send home a test with each child listed above.
________ Please send all tests home with my child: _______________ Name of child
Please sign at the bottom of this paper indicating who is making this request. Please see instructions for how to use these tests on the preceding page. By signing below, you are indicating that you understand how to use these tests and what to do should the results of the test be positive.
Parent/Guardian Name (please print): _______________________________
Parent/Guardian Signature: ______________________________