MCHS Student Athlete COVID-19 Testing Sign-Up Form, Wednesday Sept. 8, 2021

Beach Cities Health District will be providing a free molecular swab COVID test for students on Wednesday, Sept. 8 from 2-5 p.m. at Mira Costa High School in the South Bay Adult School classroom. We will be using Cue Health's rapid molecular test. Students will arrive at their scheduled time and approach the testing station. After checking in, they will be prompted to self-administer their swab test. Trained staff will oversee the swabbing to ensure accuracy. The staff member will immediately place the swab into a reader which generates a result in 20 minutes. Results will be sent via email to the parent's email address. We will inform the school of your test results.

Student First Name*

Student Last Name*

Student Date of Birth*

Sport*

We will only be testing the following teams based on competition schedule, please select your sport.

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Time Preference*

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Parent/Guardian First and Last Name*

Parent/Guardian Email Address*

Parent/Guardian Phone Number*

Student Phone Number

Optional: If a retest is needed, my student may be contacted directly by BCHD to return to the test site for a retest. Results will not be disclosed to the student. Please list student phone number below.

Parent/Guardian Permission*

The parent/guardian listed above authorizes Beach Cities Health District to conduct COVID-19 diagnostic testing for my minor child/legal dependent (the “student”) through a mid-turbinate nasal swab as ordered by an authorized medical provider. I authorize the student’s test results to be disclosed to the school representatives as deemed necessary for the enforcement of public health policy and district protocol. Individuals including but not limited to; administrators, site Principal, Vice Principals, and associated health staff. Additionally, results will be disclosed to the county, state, or to any other governmental entity as may be required by law. I acknowledge that a positive test result is an indication that the student must self-isolate and/or wear a mask or face covering as directed in an effort to avoid infecting others. I understand the testing unit is not acting as my medical provider, this testing does not replace treatment by my medical provider, and I assume complete and full responsibility to take appropriate action with regards to the students’ test results. I agree I will seek medical advice, care and treatment medical provider if I have questions or concerns, or if the student’s condition worsens. I understand that, as with any medical test, there is the potential for a false positive or false negative COVID-19 test result. I understand that student may need additional confirmatory testing depending on the test results. I, the undersigned, have been informed about the test purpose, procedures, possible benefits and risks, and I have received a copy of this Informed Consent. I have been given the opportunity to ask questions and I have been told that I can ask additional questions at any time. By checking the box below, on behalf of the student, I voluntarily agree to this testing for COVID-19.

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