Leeds City Schools School-based Student Random Drug and Alcohol Testing Program Consent Form

Leeds City Schools

School-based Student Random Drug and Alcohol Testing ProgramPupil Consent to Test Form
I understand fully that my performance as a pupil and the reputation of my school are dependent, in part, on my conduct as an individual. I hereby agree and abide by the standards, rules, and regulations set forth by the Leeds City Board of Education and sponsors-coaches for the activity in which I participate.
I authorize the Leeds City Schools to conduct a test on saliva or urine which I provide onsite to test for alcohol and/or drug use if my number is drawn from the random pool. Pursuant to the regulations for the Students Random Drug and Alcohol Testing Policy and Implementing Guidance, I also authorize the release of information concerning the results of such tests to designated personnel.
I understand that this form remains in effect until the submission of an Activity Drop Form or graduation and/or withdrawal from the school district.
Pupil name
Current grade
Pupil ID (leave blank)
Pupil signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Parent-guardian name
Contact number(s)
Please enter a valid phone number.Format: (000) 000-0000.
Parent-Guardian Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Should be Empty: