COVID-19 Test Permission Slip for Minors
Please print and bring to the test site
Please complete the information below about the student being tested for COVID-19 symptoms/exposure:
Student Name
Student Birthdate
School
Parent/Guardian Name(s)
Home Address
Phone Number
ESD 113 / North Thurst
on / Olympia / Tenino / Tumwater school districts have collaborated with the Washington State Department
of Health to be able to offer free COVID-19 testing to students.
The COVID-19 tests are quick and painless, and will be self-administered under observation by a trained person. A company called
Curative will process and analyze the test results and will share the results with the ESD 113 / North Thurston / Olympia / Tenino /
Tumwater school district (circle one) and notify the parent/guardian.
You are entitled to keep certain information about your child’s health and education private. This form allows you to grant the
school district with access to your child’s protected information that otherwise may not be permitted.
By signing below, you authorize Curative to release the results of your child’s COVID-19 test results to their school district. This
information will be used for the purpose of addressing the health and safety of students and staff through contract tracing of COVID-
19 cases in our school.
By signing below, you also authorize your child to be tested if they have symptoms or had exposure to a positive individual and for
the School District to have Curative process and analyze the test. You further authorize the School District to share your child’s
birthdate to Curative for identification purposes. Finally, you understand that, per the Washington State Department of Health, a
student with COVID-19 or COVID-19 symptoms cannot attend school onsite.
By signing below, you affirm that you have the legal authority to determine who may receive the protected health and education
information pertaining to the student.
Date: ____________
Parent/Guardian Signature: _____________________________________
Parent/Guardian Printed Name:__________________________________
Received by School District on (date):_____________________________
click to sign
signature
click to edit
![]()
