2021-22 COVID-19 Test to Stay Consent Form (Students)

Harrison Central School District

2021-22 COVID-19 Test to Stay Consent Form
The Westchester County Department of Health County (WCDOH) has granted approval for the Harrison Central School District to implement a Test to Stay (TTS) program. Effective December 20, 2021, the TTS program permits unvaccinated, asymptomatic students who have been exposed to COVID-19 to remain in school by getting tested each school day during the first seven (7) days of the 10-day quarantine. The TTS protocols are dictated by WCDOH and may be subject to change as new guidance is issued.

Students who are fully vaccinated are not required to quarantine following exposure and, therefore, do not need to participate in the TTS program.

The District will provide rapid antigen testing (minimally invasive shallow nasal swab) for unvaccinated students whose parents give consent to participate in the TTS program. The TTS program is only for unvaccinated, asymptomatic students who have had close contact with a positive case. If a student becomes symptomatic during the TTS, even with a negative antigen test, they are no longer eligible for TTS and must be excluded from school. Please carefully review the HCSD TTS webpage which provides an overview of the WCDOH program requirements and responsibilities for parents and students.

To provide consent for your child to participate in the TTS program and avoid missing school due to quarantine, please complete this consent form (you will need to complete a separate consent form for each unvaccinated child to participate in the TTS program). Your consent is valid for the 2021-22 school year.

Thank you for your partnership as we work to keep our school community healthy and safe.
Student Name*

First NameLast Name
Date of Birth*
Student Gender*

MaleFemaleOther
School this student attends for in-person learning*

Harrison High SchoolLouis M. Klein Middle SchoolHarrison Avenue Elementary SchoolParsons Memorial Elementary SchoolPurchase Elementary SchoolSamuel J. Preston Elementary School
Grade level of this student*
Parent/Guardian Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Email*
example@example.com
Parent/Guardian Phone Number*
Please enter a valid phone number.
Please review the following information and provide your consent below.
1. I have reviewed the District's Test to Stay (TTS) program and I consent for my child to participate in the TTS program to be tested for COVID-19 on a daily basis to avoid exlcusion from school following exposure to COVID-19.
2. I understand that New York State law allows some information about my child to be shared with and among certain County and New York State agencies (e.g., NYS Department of Health, Westchester County Health Department, Contracted Service Providers for COVID-19 Testing). This information will be shared only for public health purposes, which may include notifying close contacts of my child if they have been exposed to COVID-19, and taking other steps to prevent the further spread of COVID-19 in your school community. Information about my child that may be shared includes my child’s name and COVID-19 test results, date of birth/age, gender, race/ethnicity, school name(s), teacher(s), enrollment and attendance, and after school or other program participation, names of other family members or guardians, address, telephone, mobile number, and email address. Sharing of information about my child will only be done in accordance with applicable law and the Harrison Central School District’s policies protecting student privacy and the security of my child’s data.
3. I have signed this form freely and voluntarily, and I am legally authorized to make decisions for the child named above.
4. I understand that this consent form will be valid through June 30, 2022, unless I notify the designated contact person from my child’s school in writing that I revoke my consent.
5. I understand that my child’s test results and other information may be disclosed as permitted by law.
6. I acknowledge that a positive test result will require my child to be sent home from school and remain at home until he/she meets the criteria to return to school according to state and local guidelines.
7. I understand that this testing does not replace treatment by my child’s medical provider, and I assume complete and full responsibility to take appropriate action regarding my child’s health and medical care as well as in response to any test results.
8. I understand that if I am a student age 18 or older, or may otherwise legally consent for my own health care, references to “my child” refer to me and I may sign this form on my own behalf.
9. I have read this form and all of my questions have been answered to my satisfaction. By signing this form, I acknowledge that I have read and accept all of the above.
Click YES to provide consent:*

YES, I willingly and knowingly give consent to the provisions detailed above.
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Harrison Central School District