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School COVID-19 Testing Registration Form - Madison County

2. School COVID-19 Testing Registration Form - Madison County

4. First Name*

5. Last Name*

6. Date of Birth (mm/dd/yyyy)*
   Date of Birth (mm/dd/yyyy)

8. Phone Number*

9. Your Email Address*

11. Sex*
    -- Select One --MaleFemaleNon-binary

12. Race*
    -- Select One --American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian of Pacific IslanderWhiteOther race including mixed raceDecline to Answer

14. Do you have a permanent address?*
    -- Select One --YesNo

15. Ethnicity*
    -- Select One --HispanicNon-HispanicOtherDecline to Answer

17. Your Address*

19. City*

20. State*

22. Postal / Zip Code*

23. Country*

25. Name of School*

26. Department

28. Occupation*

29. School Phone Number*

31. School Street Address*

33. City*

34. State*

36. Postal / Zip Code*

37. Country*

39. 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.*

Leave This Blank:


41. 1. Receive an email copy of this form.
42. Email address

    This field is not part of the form submission.

43. Submit

* indicates a required field