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Public Health Alert
Madison County Limiting to Essential In-Person Operations Only
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School COVID-19 Testing Registration Form - Madison County
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School COVID-19 Testing Registration Form - Madison County
First Name
*
Last Name
*
Date of Birth (mm/dd/yyyy)
*
Date of Birth (mm/dd/yyyy)
Phone Number
*
Your Email Address
*
Sex
*
-- Select One --
Male
Female
Non-binary
Race
*
-- Select One --
American Indian or Alaska Native
Asian
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White
Other race including mixed race
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Do you have a permanent address?
*
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No
Ethnicity
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-- Select One --
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Other
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Your Address
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City
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State
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Postal / Zip Code
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Country
*
Name of School
*
Department
Occupation
*
School Phone Number
*
School Street Address
*
City
*
State
*
Postal / Zip Code
*
Country
*
If person to be tested is under the age of 18 provide the name of the parent / guardian providing parental consent. If person to be tested is 18 years of age or older re-enter name of patient.
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