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* 1. First Name

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* 2. Last Name

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* 3. Year Group

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* 4. Date of Birth

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* 5. Gender (this information is needed for Department for Health and Social Care research purposes).

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* 6. Ethnicity (this information is needed for Department for Health and Social Care research purposes)

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* 7. Currently showing any COVID-19 symptoms?

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* 8. Home Postcode

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* 9. Email address (this is where test results will be sent)

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* 10. Mobile Number (this is where test results will be sent.  Please do not put a landline number - you can only receive test results to a mobile number)

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* 11. Name of parent/guardian giving consent

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* 12. Relationship to test subject

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* 13. Signature (typing your name is sufficient if you are filling in this form digitally)

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* 14. Today's date

Date

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* 15. Details of any health or accessibility issues which might affect a child's safe participation in the testing exercise.

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