COVID-19 Testing Consent Form for Students Under 18

To be completed by parent or guardian. Completion of this form gives consent for your minor student to participate in testing for COVID-19 at Fulton-Montgomery Community College.

Student Name * Required
First Last
Student Email * Required
Student Phone Number * Required
Student Date of Birth - must be mm/dd/yyyy format * Required
MM slash DD slash YYYY
Student Current Age * Required
Your Name * Required
First Last
Your Relationship to Student * Required
- Parent
- Legal Guardian
Your Address * Required
Street Address Address Line 2 City State ZIP Code
Your Phone Number * Required
Your Email * Required
Consent * Required
I understand and consent to the below for my student.
Completion of this form confirms your understanding of the following:

· Your student will participate in a COVID-19 pooled testing at SUNY Fulton-Montgomery Community College at no charge to the student.

· If you do not wish for your student to test with Fulton-Montgomery Community College, your student may obtain testing at an alternate site, at your expense, in order to meet the testing mandate. The test will need to be completed within 10 days of the advertised testing dates. You should not submit this form.

· Pooled testing consists of saliva sample taken at Fulton-Montgomery Community College and combined in a random pool for testing to be performed at SUNY Upstate with Quadrant Biosciences.

· Should the random pooled test be positive, you consent to the reflex testing of your student’s individual sample.

· The student’s health insurance will be billed for reflex testing.

· With a positive pool, the reflex test results become personal and medical information that will be handled by the Vice President for Student Affairs (VPSA) at Fulton-Montgomery Community College, related laboratories, and medical professionals. The information you have entered will be available to VPSA in order to follow up with your student.

· SUNY Upstate and Quadrant Biosciences will store information obtained for testing and will utilize that information to provide medical care.

· If the pool is positive, the information shared will be provided to Fulton-Montgomery Community College who will notify both you and your student of the results via phone.

· Student will be notified by phone call from the VPSA at Fulton-Montgomery Community College with notification of positive result.

· Student and parent/guardian should be prepared to answer their phones in order to receive test results, otherwise college staff may be used to make contact with the student.

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COVID-19 Testing Consent Form for Students Under 18