To be returned to the Building Principal.  Please print.

Student                             School year            

To be read and signed by the student-participant and his/her parent(s)/guardian(s):

We have received, and have read and understand, the District Extracurricular Drug and Alcohol Testing Program.  We voluntarily agree that our child shall be subject to its terms for his or her entire high school career (grades 9-12).  We accept the method of obtaining breath and urine specimens, the testing and analyses of such specimen, and all other aspects of the program.  The student-participant agrees to cooperate in furnishing urine specimens upon request.

We further agree and consent to the disclosure of the sampling, testing, and results as provided in this program.  This consent is given pursuant to all State and federal privacy statutes, and is a waiver of nondisclosure rights only to the extent of the disclosures required in the program.

We understand that there is more information available on the following websites: ihsa.org/documents/sportsMedicine/Reso... and ihsa.org/Resources/SportsMedicine/Perf....  

Parent/Guardian                    Date

Parent/Guardian signature                Student signature

To be read and signed by student who is not participating:

I have decided not to participate in any extracurricular activities sponsored by the School District for the remainder of this school year.  In order for me to participate in the extracurricular activity program at a later date, I understand that I must submit to a urinalysis.

Student signature                    Date