JEWISH COMMUNITY CENTERS OF GREATER BOSTON, INC. 

Abbott BinaxNOW Antigen Test Parent/Guardian Authorization, Informed Consent and Waiver for Child 

By completing and submitting this form, I confirm that I am the appropriate parent, guardian or legally authorized individual to provide this authorization and consent on behalf of the below named child (the “Child”) and, in that capacity, I agree as follows:

  1. I authorize the administration of a COVID-19 antigen test on the Child as part of the testing programs to be administered by the Jewish Community Centers of Greater Boston, Inc. (the “JCC”), including during school, camping and other program hours as applicable.  
  2. I authorize an administration of an Abbott BinaxNOW COVID-19 antigen test on the Child. 
  3. I understand that the Child’s test results may be reported to me and the JCC via Abbott’s Navica system and shared with the Massachusetts Department of Public Health in accordance with state law.
  4. I agree that the JCC is not responsible for any breach of privacy resulting from the further transmission of the Child’s test results from the Abbot’s Navica System or by the Department of Public Health.
  5. I understand that all sample types will be non-invasive, short nasal swabs. 
  6. I understand and agree that the Child’s personal health information and personally identifiable information from education/program records may be entered into the testing provider’s technology platform. 
  7. I understand that there is the potential for a false positive or false negative COVID-19 test result. Given the potential for a false negative, I understand that the Child should continue to follow all local and state COVID-19 safety guidance, including, but not limited to, mask-wearing and social distancing, and follow all JCC COVID protocols and Codes of Conduct including isolating and PCR testing in the event the Child develops symptoms of or is exposed to COVID-19.
  8. I understand that staff administering the testing have received training on safe and proper test administration. I agree that neither the test administrator, testing director, nor the JCC nor any of its staff, trustees, members, officers, employees, or organization sponsors shall be liable for any loss, damage, accident or injuries that may occur or result from participation in the testing program, including, without limitation, for any claim of loss, damage or injury based on a false positive or false negative test result, all such claims for any of the foregoing being hereby waived.
  9. I understand that the Child must stay home if feeling unwell. I acknowledge that a positive test result is an indication that the Child may have COVID and must follow the JCC protocols for COVID positive individuals.
  10. I understand the JCC is not acting as the Child’s medical provider, this testing does not replace treatment by the Child’s medical provider, and I assume complete and full responsibility to take appropriate action with regards to the Child’s test results. I agree I will seek medical advice, care and treatment from the Child’s medical provider if I have questions or concerns, or if the Child’s condition worsens. I understand I am financially responsible for any care the Child receives from the Child’s healthcare provider.
  11. I understand that testing may create protected health information (PHI) and other personally identifiable information of the Child. Pursuant to 45 CFR 164.524(c)(3), I authorize and direct the testing provider to transmit such PHI to the JCC, via Abbot’s Navica System and to the Department of Public Health. I further understand that PHI may be disclosed to the Executive Office of Health and Human Services and any other party, as authorized under HIPAA.
  12. I understand that participation in testing may require JCC to disclose the Child’s identity, demographic, and contact information from education/program records to the testing provider and, for follow-up tests, will require JCC to disclose the Child’s identity, demographic, and contact information from its records to the Department of Public Health.  Pursuant to FERPA, 34 CFR 99.30, I authorize JCC to disclose such personally identifiable information (PII) as is required for the Child to participate in testing program.
  13. I understand that authorizing these COVID-19 tests for the Child is optional and that I can refuse to give this authorization, in which case, the Child will not be tested.
  14. I understand that I can change my mind and cancel this authorization at any time, but that such cancellation is forward-looking only, and will not affect information I already authorized to be released. To cancel this authorization for COVID-19 testing, I need to contact the JCC Greater Boston COVID-19 representative at COVID-questions@jccgb.org at the JCC.   
  15. I have been informed about the test purpose, procedures, possible benefits and risks, and I have received a copy of this Authorization and Consent form. I have been given the opportunity to ask questions before I sign, and I have been told that I can ask additional questions at any time. I voluntarily agree to this testing for COVID-19 for the Child. 
  16. I understand that testing is in addition to and does not substitute for health protocols already in place all of which I understand must be adhered to by me and the Child.   
  17. Electronic signatures, including, without limitation, telecopied or electronically scanned and emailed signatures, may be used in place of original signatures on this Consent and such signatures shall be binding on the signatory.

Executed as an instrument under seal. 

 

(Only one child may be listed per form submission)
Please select all programs in which your child participates:
Please list any other programs for which your child participates that are not listed above: