MERSD At-Home Testing Program - Faculty & Staff

Opt-in Form for Faculty & Staff Participating in the DESE Sponsored At-Home Antigen Test Program

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* 1. Last Name:

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* 2. First Name:

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* 3. The school building you are assigned to / work at the majority of the time.

Essex Elementary

Memorial School

Middle High School

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* 4. Have you had COVID within the past 90 days?

No

Yes

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* 5. Opt-in Form into the At-Home Antigen Test Program

Yes, I opt-in to the at-home antigen test program (please read and sign electronically below)