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COVID-19 is an infectious illness caused by a coronavirus. George Mason University is providing my minor child with the opportunity to get tested for COVID-19 so my child may meet the requirements to participate in the summer camp program.
I consent and authorize George Mason University (GMU) to conduct collection, testing and analysis of samples from my child for the purpose of a Center for Disease Control (CDC), Food and Drug Administration (FDA), Emergency Use Authorization (EUA), or CAP/CLIA approved Coronavirus (COVID-19) test. Analysis of the samples may be conducted in partnership with a third-party laboratory and/or possibly tested for variants if indicated. I acknowledge that I am giving this consent for my child to be tested voluntarily and that any testing done on my child is voluntary. I understand that my child may carry or transmit COVID-19, even if he/she does not have symptoms. I have been informed about the test purpose and procedures.
I understand possible risks include:
I understand potential benefits include:
I understand George Mason University is not acting as my child’s medical provider. This testing does not replace treatment by my child’s medical provider, and I assume complete and full responsibility to take appropriate action with regards to my child’s test results.
I understand that my child’s test results will be treated as confidential medical records. If my child’s test results in a positive or suspected positive diagnosis of COVID-19:
I understand this authorization is in effect until both the Federal Public Health Emergency declaration and the Virginia State of Emergency are revoked. I also understand that I may revoke or cancel this authorization at any time by submitting a written statement to firstname.lastname@example.org except to the extent that action has already been taken based on this authorization.
I agree to receive this form electronically and provide my authorization by electronic signature. I acknowledge that I am capable of saving, printing or otherwise retaining this form if I wish to do so.
I am eighteen (18) years of age or older.
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