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School Name:  
Student ID: *Numeric value without a leading zero  
Student Last Name:  
Confirmation Email:  
I agree that I am legally authorized to submit this information as the legal parent or guardian of the impacted student. I agree that the uploaded test result has not been altered in any way from the result provided by the medical professionals. I further agree, under penalty of law and per the Electronic Signature Act, that I am the person who is signing my name inside the electronic signature box and understand this electronic signature is considered equivalent to a signed or faxed signature.
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