Consent and Registration Form for Rapid COVID-19
Antigen Test
Tesng Facility: __________________________________________________________________________
Address: _______________________________________________________________________________
Phone:_____________________________ Organizaon: ______________________________
Tesng Date: _____________
Personal Information
First Name: ______________________ Last Name: ______________________ Middle: ________________
Phone Number: ( ) - ______ - _______ Email Address: ______________________________
DOB: (mm/dd/yyyy) ____ /____ / _______ Biological Sex: * Male * Female * Prefer not to answer
Street Address: ____________________________________________________________________
City/State/Zip: _____________________________________________________________________
Race: Please check the box next to the one that best describes your race.
 American Indian/Alaskan Nave
 Black/African American
 Asian
 White/Caucasian
 Hawaiian/ Paci2c Islander
 Other
 Unknown
Hispanic or Latino: Please check the box next to one of the following that best
describes your ethnicity.
 Lano or Hispanic
 Not Lano or Hispanic
 Unknown or Decline to specify
Arab or Middle Eastern: Please check the box next to one of the following that
best describes your ethnicity.
 Arab or Middle Eastern
 Not Arab or Middle Eastern
 Unknown or Decline to specify
Do you have symptoms related to COVID-19? Yes No Unknown
If yes, what is the date the symptoms started? ___________________________
This model consent and registraon form is provided by MDHHS as a template for schools to consider when
creang a consent form for their parcipaon in the MI Safer Sports tesng program. Schools should consult
their own legal counsel when creang a program and tesng consent form.
Northwest High School
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NS Her or llegice Helth