Student Acknowledgement Form printable pdf download

Student Acknowledgement Form

FINANCIAL SERVICES DEPARTMENT

Student Name: _______________________________________________

SS# ______-_____-______

DRUG-FREE STATEMENT

The Drug-Free Schools and Communities Act of 1989 (Public Law 101-226) requires institutions receiving federal

financial assistance to implement and enforce drug prevention programs and policies.

As a matter of policy, the College prohibits the manufacture and unlawful possession, use, or distribution of illicit

drugs and alcohol by students and employees on its property and at any school activity. Any violation of this policy

will result in appropriate disciplinary actions, up to and including expulsion (in the case of students) and termination

(in the case of employees), even for a first offense. Where it is apparent that a violation of the law has occurred, the

appropriate law enforcement authorities will be notified.

In certain cases, students and employees may be referred to counseling sources and/or substance abuse help centers.

If such a referral is made, continued enrollment or employment will be subject to successful completion of any

prescribed counseling or treatment program. Students and employees who believe they have a substance abuse

problem and are seeking treatment may contact the Director of Student Services for referral assistance. All such

matters will be handled confidentially.

STANDARDS OF CONDUCT: The rules and regulations of the College clearly prohibit the use of or distribution of

any intoxicating beverage or illicit drug while on the school premises or while on a school activity.

APPLICABLE LEGAL SANCTIONS: Legal sanctions (city/state/federal) may result in a fine and/or imprisonment.

COUNSELING AGENCIES: The following centers are available for counseling:

Alcoholics Anonymous

484-7871

University Hospital and Clinics

585-2800

Mountain Land Rehabilitation

942-3311

Alcoholism Foundation

487-3276

House of Hope

359-8374

Salt Lake Substance Abuse

468-2009

DISCIPLINARY ACTION: If a student should violate this regulation, he/she will be terminated from classes and

the violation or violations will be referred to the City Police Department. Severity of the offense and any action

needed will be determined by and enforced by the appropriate authorities.

Student Signature: ________________________________________________

Date: ____/____/____

CRC APP 01.13

Student Acknowledgement Form