State of Rhode Island
Department of Health
By checking the box below, I attest that I,
[Parent/Guardian name], authorize healthcare providers affiliated with RI public schools
(including school nurses, school nurse teachers, physicians, or other medical actors and agents) to test my child or
legal charge for COVID-19 upon determining that such testing is appropriate. I understand that this testing may occur at multiple points throughout the 2020-2021 school year. I will contact the school nurse to revoke this authorization, if I wish for testing activity to cease. By signing this form, I am attesting that I have the requisite legal authority and power to make the decisions for, and on behalf of, the student named above that I am making on this form.