COVID At-Home Test Attestation Form

Complete this form ONLY if took an At-Home COVID test. Contact Nurse Jackson with questions.

Student Name(Required)

First Last

Date of Birth(Required)

Grade(Required)

Parent Phone Number(Required)

Parent Email(Required)

List of symptoms and/or reason for testing(Required)

Date of Test(Required)

At-Home COVID Test Result(Required)

Brand of Home COVID Test(Required)

Photo of Test Results(Required)

Accepted file types: jpg, jpeg, png, gif.

I am the parent/guardian of the student listed above and I attest that the information I provided on this form is accurate and true.(Required)