COVID At-Home Test Attestation Form

Complete this form ONLY if you are symptomatic, took an At-Home COVID test, and tested positive. A negative PCR test is required to return to school. 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)

Positive

Brand of Home COVID Test(Required)

Photo of Test Results(Required)

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

Parent Electronic Signature

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)

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COVID At-Home Test Attestation Form

Parent Electronic Signature