*Required

STUDENT INFORMATION

Student full name*

Student tutor group*

Student date of birth*

Student home address*

WHO WILL THE RESULTS GO TO?

Contact name*

Relationship to student [if student is under 16]*

Email address*

Mobile telephone number*

In the case of under 16s, I have discussed the testing with my child and my child is happy to participate. If on
the day of testing they do not wish to take part, then they will not be made to do so and consent can be
withdrawn at any time ahead of the test.

Please consent to the following statements by writing ‘Yes’ or ‘No’ to each statement.
I give consent to I / my child being tested for COVID

I give consent for the school to be notified of the results

I understand that if I / my child tests positive, I / my child and household will have to self-isolate for 10 days

I consent that if a close contact of my child tests positive but I / my child has tested negative, I / they will
continue to attend school / college but will be tested every day at school / college for what would otherwise have
been the isolation period in force at the time (currently 10 days).

I consent to my / my child's data being shared with the NHS

I agree all the information above is accurate and I consent to all the statements above

Signed*

Name*

Relationship to the child*

Date*