ECSU COVID-19 Spread Mitigation Program

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ECSU COVID-19 Spread Mitigation Program - ECSU Employees

Appointment Request Form

First name *

Middle name

Last name *

Birthdate *

YYYY

Gender *

Male

Female

Prefer not to say

Ethnicity *

Black or African American

White

Hispanic/Latino

Native American/Alaskan Native

Asian

Native Hawaiian/Pacific Islander

Bi-or Multi-Racial

Prefer not to say

Street address *

City *

State *

Zipcode *

E-mail address *

Home phone (Do not include dashes)

Cell phone (Do not include dashes) *

Preferred contact *

Home phone

Cell phone

Required

Acknowledgment *

By checking this box, I confirm that I have read and agreed to the following terms of service.

Required

DISCLAIMER

1. That I am making this request voluntarily on my own
2. That I understand that the result of the test will neither be guaranteed nor certified
3. That any action that I take after receiving a test result is completely my decision
4. That I am releasing ECSU, its employees including those directly responsible for this service from all liabilities, obligations, or consequences that might be attributed fully or partly from this service

Signature *

Please print clearly.

Today's date *

YYYY

Submit

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