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.

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* 1. Parent/Guardian Name:

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* 2. Parent/Guardian Email Address:

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* 3. Student Last Name:

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* 4. Student First Name:

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* 5. Student’s Grade Level:

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* 6. School

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* 7. Student Home Room (if applicable):

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* 8. Has your student had COVID in the past 90 days?

Yes

No

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

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