Skip survey header

Consent Waiver For COVID-19 Testing

CLV Consent for Child’s COVID-19 Testing by Parent/Legal Guardian

CATTARAUGUS-LITTLE VALLEY CSD Consent for Child’s COVID-19 Testing by Parent/Legal Guardian

Parents / Guardians:

As you are likely aware, New York State is now identifying localities as micro-clusters zones when there are sharp increases in the COVID-19 infection rate. This designation by New York State comes with increased restrictions that impact school districts within an identified zone.

Should our community be designated a Yellow Zone, also known as a Precautionary Zone, the following activity restrictions will be put into place:

  • Schools must test 20% of in - person students, faculty and staff over the two-week period immediately following the announcement of a yellow zone designation. If the results of the testing reveal that the positivity rate among the 20% of those tested is lower than the yellow zone's current 7 - day positivity rate, testing at that school will no longer be required to continue. However, if the results of the testing over the first two weeks reveal that the positivity rate among in - person student, staff and faculty is higher than the Yellow Zone's current 7 - day positivity rate, the school will be required to continue to test 20% of the in - person population on a bi-weekly basis.

Furthermore, schools may remain open for in - person instruction if they adhere to required testing regulations. Students who are selected for testing must have a completed consent form on file to be tested. 

Thank you for your continued flexibility and cooperation as we continue to strive to provide in-person learning opportunities for students and a safe learning environment for our entire school community.


Sharon Huff

1. Student's Full Name: *This question is required.
2. Copy of Student's Full Name: *This question is required.

The CATTARAUGUS-LITTLE VALLEY CENTRAL SCHOOL DISTRICT (the “District”) is seeking your consent to test your child for COVID-19 infection. If you consent, your child may receive a free rapid antigen test for the COVID-19 virus that will be administered by a health professional from the County Health Department.

A rapid COVID-19 test will be used, which will involve inserting a small swab, similar to a Q-Tip, into the front of the nose. You will be notified by the County Health Department, or the District if instructed by the County Health Department, if your child tests positive for COVID-19.

Any students who test positive will be sent home and must be kept at home until meeting Cattaraugus County Health Department criteria to return to school. Please contact your child’s doctor immediately to review the test results should your child test positive for COVID-19.

The law requires and/or allows some information about your child to be shared with Cattaraugus County and New York State Public Health Agencies. This includes notifying the Cattaraugus County Health Department about the COVID-19 results of each student who is tested, including the student’s name, date of birth, race, ethnicity, gender, address, phone number, and result of the COVID-19 test.

This question requires a valid date format of MM/DD/YYYY.

By signing below, I attest that:

  • I have signed this form freely and voluntarily, and I am legally authorized to make decisions for the child named above.
  • I consent to my child being tested for COVID-19 infection.
  • I understand that my child may be tested at multiple times during the 2020-2021 school year.
  • I understand that this consent form will be valid through June 30, 2021, unless I revoke such consent in writing.
  • I understand that my child’s test results and other information may be disclosed as permitted by law.

I hereby give my consent to Cattaraugus-Little Valley CSD or any person or agency acting as an agent for Cattaraugus-Little Valley CSD for COVID-19 testing for my child.

*This question is required.
Signature of