Ems-Isd Mandatory Drug Testing Consent, Release, And Hold Harmless Agreement

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EMS-ISD MANDATORY DRUG TESTING CONSENT, RELEASE,
AND HOLD HARMLESS AGREEMENT
I, ___________________________________________________ (name of parent/guardian) am a parent/guardian
of ______________________________________ (name of student), a student enrolled in the Eagle Mountain-
Saginaw  Independent  School  District  (“EM-S  ISD”)  at  _________________________________ (name of campus).
My child intends to participate in one or more of the following extracurricular activities: school-sponsored athletics, band,
cheerleading,  dance,  choir,  and/or  UIL  academic  activities  (‘Extracurricular  Activities,”  whether  one  or  more).   My child and I
understand that participation in Extracurricular Activities is a privilege, not a right, and compliance with EM-S   ISD’s   drug  
testing  program  is  a  condition  to  my  child’s  participation  in  Extracurricular  Activities.  
We have read and understand EM-S  ISD’s  policy  (available  online)  for  testing  student urine samples for prohibited substances
including without limitation the following: alcohol, amphetamines, methamphetamines, barbiturates, benzodiazepines, cocaine
metabolite, marijuana, methadone, opiates, phencyclidine, propoxyphene, hallucinogens, steroids, and all other illegal,
addictive, or performance-enhancing drugs. We understand that all students in grades 7-12 who participate in Extracurricular
Activities will be subject to random drug testing during the school year. Urine samples will be taken under conditions that are
no more intrusive to students than the conditions experienced in a public restroom. We understand that EM-S ISD has
contracted   with   FORWARD   EDGE,   INC/RON’S   24   HOUR   MOBILE   DRUG   &   ALCOHOL   TESTING   to collect urine
samples for the purpose of testing for the presence of drugs and/or alcohol. We understand that if a test of the child’s  urine  
sample reveals the presence of a Prohibited Substance, EM-S ISD may take action against him/her up to and including
termination of the child’s  participation  in  Extracurricular  Activities.  
HAVING READ EM-S ISD’S   DRUG   TESTING POLICY AND THIS CONSENT FORM, WE REPRESENT THAT WE HAVE
THE AUTHORITY TO CONSENT TO THE DRUG TESTING OF THE CHILD AND WE HEREBY AUHORIZE THE
COLLECTION OF URINE SAMPLES FROM THE CHILD FOR THE PURPOSE OF TESTING OF PROHIBITED
SUBSTANCES. THIS AUTHORIZATION INCLUDES, BUT IS NOT LIMITED TO, AUTHORIZATION FOR FORWARD
EDGE,  INC/RON’S  24  HOUR  MOBILE  DRUG  &  ALCOHOL  TESTING  TO  COLLECT  URINE  SAMPLES  FROM  THE CHILD
FOR THE PURPOSE OF TESTING FOR THE PRESENCE OF DRUGS AND/OR ALCOHOL.
We further authorize EM-S ISD, and/or FORWARD   EDGE,   INC/RON’S   24   HOUR   MOBILE   DRUG   &   ALCOHOL  
TESTING, and their officers, employees, and agents to communicate the child’s  drug  test  results  both  orally  and  in  writing  to  
each other, to us and the child’s   other   parent/guardian,   and/or   to   EM-S ISD administrators and personnel responsible for
administering the testing program and extracurricular activities, and to communicate such test results at any EM-S ISD
administrative or any other legal proceeding. I understand that the child’s  drug  test results shall not be maintained in the child’s  
educational file and shall be destroyed when the child graduates from high school. If the child graduates from a high school not
part of EM-S ISD, then it shall be our responsibility to notify EM-S ISD of the child’s  graduation  so  that  the  drug  test  results  
can be destroyed. We also understand that no physician/patient relationship is established by the collection of urine samples by
the designated, licensed medical facility or third party administrator. We understand that, except as set forth above, all tests
results shall be confidential and shall be disclosed only to the child, to me and to the child’s  other  parent/guardian,  and/or  to  
designated district officials.
WE HEREBY RELEASE AND HOLD HARMLESS EMS-ISD AND FORWARD  EDGE,  INC/RON’S  24  HOUR  MOBILE  DRUG  
& ALCOHOL TESTING, AND THEIR BOARD OF TRUSTEES, OFFICERS, EMPLOYEES, AGENTS, REPRESENTATIVES,
AND MEDICAL STAFF MEMBERS FROM ANY AND ALL LIABILITY, CLAIMS, DAMAGES AND COSTS THAT MAY
ARISE FROM OR BE RELATED DIRECTLY OR INDIRICTLY TO A DRUG TEST.
THIS IS A LEGAL CONSENT AND RELEASE OF LIABILITY FORM. PLEASE READ THIS FORM CAREFULLY AND BE
SURE YOUR QUESTIONS HAVE BEEN ANSWERED BEFORE SIGNING.
THIS CONSENT, RELEASE, AND HOLD HARMLESS AGREEMENT SHALL BE EFFECTIVE AS LONG AS THE CHILD IS
ENROLLED AT THE EM-S ISD SCHOOL CAMPUS DESIGNATED ABOVE, OR UNTIL WRITTEN NOTICE OF
REVOCATION OF THIS CONSENT IS GIVEN TO THE PRINCIPAL OF SUCH SCHOOL.
Parent/Guardian Signature
Date
Student ID Number
Printed Name of Parent/Guardian
Student Signature
Revised August 2011

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