EMSISDMandatoryDrugTestingConsent,Release,andHoldHarmlessAgreement

I,_____________________________________________(Parent/GuardianName)amaparent/guardianof___________________________________________________(StudentName),astudentenrolledintheEagleMountain-SaginawISDat______________________________________(campus).Mychildintendstoparticipateinoneormoreofthefollowingextracurricularactivities:school-sponsoredathletics,band,cheerleading,dance,gymnastics,swimming,choir,and/orUILacademicactivities(“ExtracurricularActivities,”whetheroneormore).MychildandIunderstandthatparticipationinExtracurricularActivitiesisaprivilege,notaright,andcompliancewiththeEMSISDdrugtestingprogramisaconditiontomychild’sparticipationinExtracurricularActivities.WehavereadandunderstandtheEMSISDpolicyFNF(Local),fortestingstudenturinesamplesforprohibitedsubstancesincludingwithoutlimitationthefollowing:alcohol,amphetamines,methamphetamines,barbiturates,benzodiazapines,cocaine,metabolite,marijuana,methadone,opiates,phencyclidine,propoxyphene,hallucinogens,steroids,andallotherillegaladdictive,orperformance-enhancingdrugs(policyavailableontheEMSISDwebsite).WeunderstandthattheEMSISDhascontractedwithMelody’sSouthwestConsortiumtocollecturinesamplesforthepurposeoftestingforthepresenceofdrugsand/oralcohol.Weunderstandthatifatestofthechild’surinesamplerevealsthepresenceofaprohibitedsubstance,EMSISDmaytakeactionagainsthim/heruptoandincludingterminationofthechild’sparticipationinExtracurricularActivities.HavingreadEMSISD’sdrugtestingpolicyandthisconsentform,werepresentthatwehavetheauthoritytoconsenttothedrugtestingofthechildandweherebyauthorizethecollectionofurinesamplesformthechildforthepurposeoftestingofprohibitedsubstances.Thisauthorizationincludes,butisnotlimitedto,authorizationforMelody’sSouthwestConsortiumtocollecturinesamplesfromthechildforthepurposeoftestingforthepresenceofdrugsand/oralcohol.WefurtherauthorizeEMSISD,andMelody’sSouthwestConsortium,andtheirofficers,employees,andagentstocommunicatethechild’sdrugtestingresultsbothorallyandinwritingtoeachother,tousandthechild’sotherparent/guardian,and/ortoEMSISDadministratorsandpersonnelresponsibleforadministeringthetestingprogramandextracurricularactivities,andtocommunicatesuchtestresultstoanyEMSISDadministrativeoranyotherlegalproceeding.Iunderstandthatthechild’sdrugtestingresultsshallnotbemaintainedinthechild’seducationalfileandshallbedestroyedwhenthechildgraduatesfromhighschool.IfthechildgraduatesfromahighschoolnotpartofEMSISD,thenitshallbeourresponsibilitytonotifyEMSISDofthechild’sgraduationsothatthedrugtestingresultscanbedestroyed.Wealsounderstandthatnophysician/patientrelationshipisestablishedbythecollectionofurinesamplesbythe

designated,licensedmedicalfacilityorthird-partyadministrator.Weunderstandthat,exceptassetforthabove,alltestresultsshallbeconfidentialandshallbedisclosedonlytothechild,tomeandtothechild’sotherparent/guardian,and/ortodesignatedDistrictofficials.WeherebyreleaseandholdharmlessEMSISDandMelody’sSouthwestConsortium,andtheirBoardofTrustees,officers,employees,agents,representatives,andmedicalstaffmembersfromanyandallliability,claims,damagesandcoststhatmayarisefromorberelateddirectlyorindirectlytoadrugtest.Thisisalegalconsentandreleaseofliabilityform.Pleasereadthisformcarefullyandbesureyourquestionshavebeenansweredbeforesigning.Thisconsent,release,andholdharmlessagreementshallbeeffectiveaslongasthechildisenrolledattheEMSISDschoolcampusdesignatedabove,oruntilwrittennoticeofrevocationofthisconsentisgiventothePrincipalofsuchschool.______________________________________________________ __________________Parent/GuardianSignature Date______________________________________________________ PrintedNameParent/Guardian______________________________________________________ ___________________StudentSignature Date______________________________________________________ StudentID#:________________________PrintedNameStudent