COVID Test Authorization

I, on behalf of my child or an individual to whom I provide guardianship (“Child”), authorize a saliva test for COVID-19 Test (“Specimen Collection”). I, on behalf of Child, further understand, agree, certify and authorize the following:

  1. I understand that Child is a student in the Hillsborough School District (“School”) and that School, along with OmeCare (“MD/Lab”), a volunteer on behalf of School, are coordinating to collect and test Child’s saliva specimen (“Specimen”). On behalf of School, MD/Lab will order Specimen Collection and volunteers for School will distribute and collect Specimen Collection kits and deliver them to OmeCare (“Laboratory”) for laboratory analysis and reporting regarding Child’s Specimen.
  2. I, on behalf of Child, authorize MD to order Specimen Collection, volunteers for School to collect Specimen Collection and deliver it to Laboratory, and Laboratory to test and report on Child’s Specimen as further specified herein.
  3. I, on behalf of Child, understand that as the doctors ordering the Specimen Collection, MD will receive the results of Child’s test results from Laboratory. By signing below, I, on behalf of Child, am authorizing MD to access data entered on either the submitted paper form or online form. I authorize MD to release the results of Child’s test to School . I, on behalf of Child, acknowledge and agree that Child’s School will receive my child’s or an individual to whom I provide guardianship’s test results.
  4. I understand that no doctor-patient relationship between MD/Lab and Child is created by Child’s participation in testing. I, on behalf of Child, understand that none of MD, volunteers for School or Laboratory or their employees, agents, representatives, successors and assigns are acting as Child’s medical provider. Testing does not replace treatment by Child’s medical provider. I represent that, with respect to Child, it is my sole responsibility to take any appropriate action, including seeking any medical care, following the receipt of the test results from the Laboratory.
  5. I, on behalf of Child, understand that Specimen processing and results reporting may vary.
  6. I, on behalf of Child, understand and acknowledge that (a) negative results do not rule out SARS-CoV-2 infection (the virus commonly referred to as “coronavirus”), particularly those that have been in contact with the virus, (b) as with any medical test, there is a potential for false positive or false negative test results from the Laboratory, and (c) there are certain inherent risks associated with Specimen Collection (collectively, “Understood Risks”). I hereby (x) consent for myself, Child, my heirs, executors, administrators, assigns or personal representatives, knowingly and voluntarily agree to have Child’s Specimen Collection ordered by MD, distributed and collected by volunteers for School and analyzed by Laboratory; (y) waive any and all rights, claims or causes of action of any kind whatsoever arising out of Specimen Collection, any activity contemplated by this agreement, or Understood Risks; and (z) do hereby release and forever discharge MD, volunteers for School and Laboratory and their employees, agents, representatives, successors and assigns for any physical or psychological injury including but not limited to illness, paralysis, death, economical or emotional loss that I or Child may suffer as a direct or indirect result of Specimen Collection, any activity contemplated by this agreement, or Understood Risks.
  7. I, on behalf of Child, agree to indemnify and hold harmless MD/Lab, volunteers for School, Laboratory, their employees, agents, representatives, successors and assigns, against any and all claims, suits, or actions of any kind whatsoever for liability, damages, and/or compensation otherwise brought by any person as a result of any activity contemplated by this Agreement, including reasonable attorney’s fees and any related cost. 8. If any clause of this agreement is deemed unenforceable, all other clauses of this agreement shall remain in full force and effect.

I, on behalf of Child, acknowledge that I have read, understand, agree, certify and/or authorize information above.

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