Covid 19 Permission

*First Name:

*Last Name:

*Minor's Grade

*DOB:

(MM/DD/YYY)

*Preferred Parent/Guardian Phone Number

*Minor’s Address:

I authorize that a test sample be taken for COVID-19 by Capital Diagnostics in conjunction with Norwood School through the June of 2021. By signing below, I authorize Capital Diagnostics to verify my insurance benefits and submit my claim to insurance or the HRSA Covid fund in case I do not have insurance for the 2020 calendar year. If my insurance does not cover these costs, Norwood School will pay for testing expenses. Please contact Alex Ragone if you have questions. 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.

*I give permission for my child to be taken for an on-site COVID test by their teacher or designated school employee:

yes

no

By entering my digital signature below, I certify that I am the parent of the minor above I have the legal authority, based on the relationship to the child as indicated above pursuant to s. 743.0645, F.S., to consent to this test administration for the child named above.

*Digital Signature