SHIELD OPT IN CONSENT 2021-2022

 
 
  

 
  NORTH SHORE SCHOOL DISTRICT 112 STUDENT INFORMED CONSENT SHIELD TESTING
   
  North Shore School District 112 (“District”) seeks to maintain a safe environment for employees, students, and their families in light of the COVID-19 outbreak. This Informed Consent form provides your consent for your student to participate in a diagnostic PCR test and for the District to disclose the results as permitted or required by law or guidance.
   
  Overview
   
  By signing below, you voluntarily consent to the administration of a PCR test from Passport Health (“Test”), including the collection, testing, and analysis of a specimen via a saliva sample. This test is completely voluntary and will not be administered absent consent as memorialized on this form.
By signing below, you knowingly and voluntarily assume and accept all risks associated with the Test, including potential injury, illness, allergic reaction, and other potential risks of which you may not presently be aware.
The Test results may not be sufficient to detect or rule out the possibility that you have been exposed to or are infected with COVID-19 and there is the potential for a false positive or false negative Test result. The Test does not replace treatment by a medical provider, and you are responsible for taking appropriate action with regard to your Test results. You have the right to discuss the proposed Test with your medical provider, to learn about the purpose, potential risks and benefits of the Test.
Please note that self-certification of symptoms is still required. Do not come to school if you are exhibiting any symptoms of COVID-19. You will still be expected to quarantine consistent with the Illinois Department of Public Health’s guidance and District rules.

   
  Disclosure of Protected Health Information
   
  The District will use and share the following information in the manner described below:
The District and Passport Health may disclose your name, contact information, and Test results (positive and negative) to each other; and
The District may disclose your name, contact information, and any positive Test results to the Illinois Department of Public Health and Lake County Public Health Department, as applicable, to facilitate contact tracing and to comply with any applicable reporting requirements; and
As otherwise permitted or required by law or guidance.

   
1.
*
 
   
2.
*
 
   
3.
*
 
   
4.
*
 
   
  Waiver of Liability
By signing this Consent and Waiver, you agree to waive, release, indemnify, hold harmless, and covenant not to sue North Shore School District 112, and its Board of Education, individual Board members, employees, agents, representatives, volunteers, insurers, assigns, and successors, and each and every one of them, from and against any and all claims, demands, suits, liabilities, and causes of actions, whether known or unknown, past, present, or future, including, but not limited to, any and all costs, expenses, and attorneys’ fees, by reason of injury, illness, allergic reaction, property damage, loss, or death, arising out of, in connection with, or in any manner related to the Test, including administration of the Test, any inaccurate Test results, any resulting medical advice, course of treatment, or diagnosis, or the District’s sharing of your Test results.

   
5.
*
 
*

   
  This consent and authorization is effective upon signature and will be valid through June 30, 2022, unless revoked in a written notice to the District.
   
 
 
 
 Done