Consent Form for Minors Undergoing COVID 19 Testing
Dunkleys Gymnasics Camp is planning to provide COVID-19 Testing as a means of keeping your child and
our Camp Community safe. We are seeking your consent to test your child for COVID-19 infection. We will
test 8 year olds and up (that are not currently vaccinated) once a week. With your consent, your child will
receive a free diagnostic PCR test for the COVID-19 virus. Collecting a specimen for testing involves inserting
a small swab, similar to a Q tip, into the front of the nose. We will notify you when your child has been tested
and notify you within 24-48 hours, if your child tests positive.
In the event that your child tests positive, we will quarantine your child, and ask that you arrange for immediate
transport directly to your home. Your child and family should quarantine immediately. Your child may return
later in the summer for another session of camp, after 14 days have passed without symptoms.
In the event that your child tests negative, but still has symptoms, we will follow up with an antigen test and
work with your family to determine the cause. Your child will be quarantined at camp, until we get a negative
antigen test as well, or a Dr. has ruled out COVID as the cause of the symptoms.
Notification of Information Sharing:
The information about your minor and his/her test results will be shared with and among certain VT agencies,
contractors and providers to support the testing program. This information will be shared only for public
health purposes, which may include notifying close contacts of your minor, if they have been exposed to
COVID 19 and taking other steps to prevent the further spread of COVID 19 at Camp. Sharing of
information about your minor will ONY be done so in accordance with applicable law protecting minors’
privacy and the security of your minor’s data.
As the parent/guardian of the minor camper named below, I authorize Dunkleys Gymnastics Camp and CEC
testing personnel to collect and test a nasal sample from said child for the presence of COVID -19 in order to
access and remain at Dunkleys Gymnastics Camp.
Furthermore, I understand the potential risks of this procedure include:
- Possible discomfort or other complications that can happen during sample collection
- Possible false positive, false negative or inconclusive test results
Potential benefits include:
The result, along with other information, can help you make informed decisions about your child’s
The results of this test will help limit the spread of COVID 19 to your family, others in your
community and the Dunkleys Gymnastics Camp Community.
By filling out the form and signing below, I attest that:
- I consent for my minor to be tested for COVID-19 infection.
- I understand that my minor may be tested multiple times, if they are at camp more than 1 week.
- I understand that this consent form will be valid through the end of Camp, August 20, 2022.
- I understand that my minor’s test results may be disclosed as specified above and permitted by law.
- I have signed this form freely and voluntarily, and I am legally authorized to make decisions for the
minor named below.
and have the legal authority based on the relationship to this child to consent to this test administration.