MERSD At-Home Testing Program - Students
Opt-in Form for Students Participating in the DESE Sponsored At-Home Antigen Test Program
Please complete a separate form for each student participating n the program.
OK
*
1.
Parent/Guardian Name:
(Required.)
*
2.
Parent/Guardian Email Address:
(Required.)
*
3.
Student Last Name:
(Required.)
*
4.
Student First Name:
(Required.)
*
5.
Student’s Grade Level:
(Required.)
*
6.
School
(Required.)
Essex Elementary
Memorial School
Middle School
High School
7.
Student Home Room (if applicable):
*
8.
Has your student had COVID in the past 90 days?
(Required.)
Yes
No
*
9.
Opt-in Form into the At-Home Antigen Test Program
(Required.)
Yes, I opt-in my student to participate in the at-home antigen test program (please read and sign electronically below)
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