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

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

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

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