Fillable Wisd Random Student Drug Testing Permission Form printable pdf download

WISD Random Student Drug Testing Permission Form (Grades 7‐12)

*** YOU MUST COMPLETE AND RETURN THIS FORM TO YOUR CHILD'S CAMPUS ***

School:

Activity:

Grade:

Select School

Select Grade

Student's Name (Print):

Student ID (if known):

We, ____________________________ as the parents or guardians of student, ____________________ acknowledge our child

participates in extracurricular activities at Waller Independent School District and such is required to participate in the Mandatory

Random Drug Testing Program. We also acknowledge that our child will be participating in the Mandatory Random Drug Testing

Program if he/she applies for a parking permit at Waller High School.

We understand and agree that participation in extracurricular activities and having a parking permit is a privilege that may be

withdrawn for violations of Waller ISD Policies.

Waller Independent School District will be testing for the following drugs: Amphetamines, Barbiturates, Benzodiazepines,

Marijuana, Cocaine, Ethanol, Xanax, Methadone, Opiates, Phencyclidine, Propoxyphene, and Steroids. The District shall reserve the

right to test for any and all illegal or controlled substances as determined at the discretion of the District.

We acknowledge that we have received a copy of the Waller ISD Local Policy on the Mandatory Random Drug Testing Program for

Waller ISD extracurricular activities and receipt of a parking permit. We understand and agree that we are bound by all the

provisions in said program as it now exists and may hereafter, be amended. We have read and understand the drug testing

program as set forth in the policy. We hereby consent and agree to the testing of our child as provided in said program. We

understand participation in extracurricular activities and receiving a parking permit at Waller ISD is conditioned upon the voluntary

consent and participation of the drug testing policy.

We grant permission for the Medical Review Officer to contact the student and parents if a drug test is positive. The purpose of the

contact with the Medical Review Officer is to find out if there is a potential reason that the Medical Review Officer should determine

the positive test to be negative. We are aware that the vendor/MRO will contact us in reference to a positive test.

In consideration of the benefits afforded our child and us from this activity, we hereby grant permission for our child to participate in

this program. We further authorize the officers, employees, and agents of the lab WISD chooses to use to communicate our child’s

drug/alcohol test results both orally and in writing to the Waller ISD designated administrators. We understand that this

information will not become part of the child’s medical record. We understand no physician/patient relationship is established by

the collection of this urine sample by the Certified Laboratory. We further release and discharge Waller ISD, its employees, trustees,

and officials from any liability relating to the administration of the drug testing program. Also, we sign this release at our own free

will and without coercion.

THIS IS A LEGAL CONSENT AND RELEASE FORM.

PLEASE READ IT CAREFULLY AND BE SURE YOUR QUESTIONS HAVE BEEN ANSWERED BEFORE SIGNING.

Executed this _____day of _____________, 201__ in Waller, Harris County, Texas.

Parent/Guardian Signature

Daytime Phone Number

Parent/Guardian Signature

Daytime Phone Number

I, the student mentioned above, acknowledge that I have read the foregoing consent and release and I understand it and agree to be bound by its

terms and the terms of the drug testing program.

Student Signature

Student ID

Date

In the event that the student is over the age of 18 years, the student is agreeing to be contractually bound by the release as an adult.

Student Signature

Date

Wisd Random Student Drug Testing Permission Form

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