Madison College COVID-19 Testing Acknowledgements

Please provide the following information for verification purposes:

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* 1. Your full name

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* 2. Date of Birth

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* 3. Your Madison College email address (ending in @madisoncollege.edu)

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* 4. Your primary phone number (including area code)

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* 5. Can you receive text messages at this phone number?

Yes

No

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* 6. What is your current address?

Street

City

State

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* 7. Please pick your status from the list below

Student

Faculty or Staff

Other (please specify)