Please complete one form for each student at ECFS.
This form is secure and HIPAA-compliant .
I acknowledge that I am the patient providing the sample or the parent/guardian of the child providing the sample, and I am either (1) at least 18 years of age or (2) I am legally recognized as an ‘emancipated minor’ by the state in which I reside.
You consent to allow Everpoint Medical, PLLC in conjunction with Everpoint Health, LLC and its partnering laboratory (collectively, “Everpoint”) to perform a COVID-19 screening procedure (“COVID Screening Test”) on you at the request of Ethical Culture Fieldston School ("ECFS"). You further consent to allow Everpoint share the results of the COVID Screening Test with ECFS based on ECFS' need to maintain a safe environment for its employees, students, contractors, vendors, and other essential persons. By signing below, you are indicating that you voluntarily consent to the COVID Screening Test for the detection of COVID-19. The COVID Screening Test being administered involves a saliva sample or nasal swab that will be tested to indicate the potential presence of COVID-19. This test alone may not be sufficient to detect or rule out the possibility that you have been exposed to or are infected with COVID-19. You should carefully monitor your own symptoms and, notwithstanding the results of any testing, you must stay home and consult with your physician if you experience symptoms of COVID-19. Everpoint has been engaged by ECFS for the sole limited purpose of providing COVID Screening Tests and disclaims any obligation to treat you or provide you with any medical care. You have the right to discuss the COVID Screening Test with your own physician, to learn about the purpose, potential risks and benefits of any testing. Based upon your test results, you should contact your physician or other medical professional for advice and medical care. Because of the ongoing public-health crisis, it may be necessary for Everpoint and/or ECFS to share the results of your COVID Screening Test with public health authorities. By signing below, you consent to the disclosure of COVID Screening Test to public health authorities as requested, recommended or required by federal, state, and local public health authorities. You also consent to the disclosure of the COVID Screening Test result to ECFS. By signing below, you, on behalf of yourself, your heirs, executors, administrators, assigns, or personal representatives and agree to forever release and waive any claim arising from your selection to receive this COVID Screening Test that may arise against ECFS and Everpoint and their affiliates, managers, members, agents, staff, heirs, representatives, predecessors, successors and assigns. Additionally, you agree to forever release and waive any claim that might arise against ECFS and its Everpoint and staff members for any risks, side effects, or complications resulting from the COVID Screening Test. You agree to indemnify and hold harmless Everpoint and ECFS and their affiliates, managers, members, agents, staff, heirs, representatives, predecessors, successors and assigns against any and all claims, suits, or actions of any kind whatsoever for liability, damages, compensation, or otherwise brought by you or anyone on your behalf, including attorney’s fees and any related costs, if litigation arises pursuant to any claims made by you or by anyone else acting on your behalf.
Thank you for your registration!