COVID-19 Testing Program Enrollment

COVID-19 Testing Program Enrollment

New Jersey Schools
To enroll your New Jersey school or school district in the Mirimus COVID Testing Program, please complete this form. After form submission, a Mirimus representative will contact the Primary Contact for program setup.
School or District Information
School or District Name *
How many schools in your district? *
How many people do you plan to test weekly?
Who will be testing? *

Staff Students Students and Staff
When do you plan to start the testing program? *

Month Day Year
Date
Contacts
Please provide at least 1 contact as primary, onsite coordinator, and restults administrator. One contact can be all 3.
Contact 1 Name *

First Name Last Name
Contact 1 Title *
Contact 1 Email *
example@example.com
Contact 1 Phone *
Please enter a valid phone number.
Contact 1 Type *

Primary Onsite Coordinator Results Administrator
Contact 2 Name

First Name Last Name
Contact 2 Title
Contact 2 Email
example@example.com
Contact 2 Phone
Please enter a valid phone number.
Contact 2 Type

Primary Onsite Coordinator Results Administrator
Contact 3 Name

First Name Last Name
Contact 3 Title
Contact 3 Email
example@example.com
Contact 3 Phone
Please enter a valid phone number.
Contact 2 Type

Primary Onsite Coordinator Results Administrator
Notes
Provide any additional details about testing program needs.
Should be Empty:

School or District Information