DSHS TESTING - MIDWAY ISD - Formstack

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Midway Independent School District

K-12 COVID-19 Testing Program

Name of Person Being Tested | Nombre de la persona examinada*

First Name*

Last Name*

Date of Birth for Person Being Tested | Fecha de nacimiento de la persona examinada*

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Month

Day

Year

Testing Location | Ubicación del examen*

Castleman Creek Elementary Hewitt Elementary Midway Middle School Midway High School Panther Stadium River Valley Intermediate South Bosque Elementary Speegleville Elementary Spring Valley Elementary Woodgate Intermediate Woodway Elementary

Is the individual a student or a faculty/staff member? | ¿El individuo es un estudiante o miembro de la facultad/personal?*

Student Faculty/Staff

Staff or Student ID | Identificación del personal o del estudiante*

You will need to have this number on site for testing check-in.

By clicking below, you are acknowledging that the person to be tested is a minor student, their parent or guardian must proceed with registration and consent signature. | Al hacer clic, reconoce que la persona a ser examinada es un estudiante menor de edad, y su padre o tutor debe proceder con la inscripción y la firma de consentimiento.*

I agree | Estoy de acuerdo

Parent or Guardian for the Student | Padre o tutor del estudiante*

First Name*

Last Name*

Best Contact Phone Number for Parent/Guardian | Mejor número de teléfono del padre/tutor*

Best Contact Phone Number | Mejor número de teléfono*

Do you consent to receiving test results via email? | ¿Acepta recibir los resultados por correo electrónico?*

Yes. Please email my results. | Sí No. Please only call me with my results. | No

Email Address for Parent/Guardian | Correo electrónico del padre/tutor*

Confirm Email Address for Parent/Guardian | Correo electrónico del padre/tutor *

Email Address | Correo electrónico*

Confirm Email Address | Correo electrónico *

Informed Consent for K-12 COVID-19 Testing Program

CONSENTIMIENTO INFORMADO PARA EL PROGRAMA DE PRUEBAS DE K-12 PARA COVID-19

I consent to being tested under the terms and conditions above. | Doy mi consentimiento para ser examinado(a) bajo los términos y condiciones anteriores.*

Use your mouse or finger to draw your signature above

Informed Consent Signature Date/Time*

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Month

Day

Year

Hour

Minute

:

AM/PM

Resulting

PATIENT TEST RESULTS

Results Entry Date/Time*

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Month

Day

Year

Hour

Minute

:

AM/PM

Name of staff member REPORTING the results:*

First Name*

Last Name*

SARS Antigen Results*

Negative Positive Inconclusive Results; patient will need to be retested

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