BLUE MOUNTAIN SCHOOL DISTRICT CONSENT TO VOLUNTARY DRUG TESTING AND AUTHORIZATION FOR RELEASE OF INFORMATION (Minor)

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Juniper Bradford
6 years ago
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1 ATTACHMENT 1 CONSENT TO VOLUNTARY DRUG TESTING AND AUTHORIZATION FOR RELEASE OF INFORMATION (Minor) provisions of the drug testing program and agree to voluntarily comply with the terms and conditions set forth by the policy. I hereby consent and authorize the School District to collect a urine testing sample from my child-student and to have such sample tested for the presence of certain drugs and substances in accordance with the provisions of the policy. I further authorize the Superintendent of the School District or his/her designee to release the results of the drug testing of my child-student in accordance with the policy, only when necessary, to the school principal, Athletic Director, extracurricular and/or cocurricular head coach/advisor and/or members of the Student Assistance Program. I hereby acknowledge that this voluntary Consent shall remain valid unless and until I notify the Blue Mountain School District, by completion of the proper forms, of my desire to remove my child-student from the School District s drug testing program. I hereby release and discharge, for myself and my child-student, the School District and its administrators, directors, officers, employees, and agents from and of all claims, rights, expenses, debts, demands, costs, contracts, liability, obligations, actions, and causes of action of every nature, known or unknown, whether in law or equity, which I or my child-student had, now has, or may have which is in any way connected with, or arises out of the drug testing process of the policy. Printed Parent/Guardian Name Parent/Guardian Signature Date Parent/Guardian Contact Number

2 ATTACHMENT 1A CONSENT TO VOLUNTARY DRUG TESTING AND AUTHORIZATION FOR RELEASE OF INFORMATION (Adult Student) provisions of the drug testing program and agree to voluntarily comply with the terms and conditions set forth by the policy. I hereby consent and authorize the School District to collect a urine testing sample from me and to have such sample tested for the presence of certain drugs and substances in accordance with the provisions of the policy. I further authorize the Superintendent of the School District or his/her designee to release the results of my drug testing in accordance with the policy, only when necessary, to the school principal, Athletic Director, extracurricular and/or cocurricular head coach/advisor and/or members of the Student Assistance Program. I hereby acknowledge that this voluntary Consent shall remain valid unless and until I notify the Blue Mountain School District, by completion of the proper forms, of my desire to remove me from the School District s drug testing program. I hereby release and discharge the School District and its administrators, directors, officers, employees, and agents from and of all claims, rights, expenses, debts, demands, costs, contracts, liability, obligations, actions, and causes of action of every nature, known or unknown, whether in law or equity, which I had, now have, or may have which is in any way connected with, or arises out of the drug testing process of the policy. *Printed Parent/Guardian Name *Parent/Guardian Signature Date *Parent/Guardian Contact Number *This signature is not required but is provided as a courtesy to parents/guardians of adult students to insure their knowledge of this agreement.

3 ATTACHMENT 2 CONSENT TO MANDATORY DRUG TESTING OF SAMPLES AND AUTHORIZATION FOR RELEASE OF INFORMATION (Minor) provisions of the drug testing program and agree to comply with the terms and conditions set forth by the policy. I hereby consent and authorize the School District to collect a testing sample from my childstudent and to have such sample tested for the presence of certain drugs and substances in accordance with the provisions of the policy. I further authorize the Superintendent of the School District or his/her designee to release the results of the drug testing of my child-student s sample in accordance with the policy, only when necessary, to the school principal, Athletic Director, head coach and/or advisor of any extracurricular/cocurricular activity in which my child-student participates and/or members of the Student Assistance Program. I hereby acknowledge that this Consent shall remain valid unless and until I notify the Blue Mountain School District, by the completion of the proper forms, of my desire to remove my child-student from the School District s drug testing program. I hereby release and discharge, for myself and my child-student, the School District and its directors, administrators, officers, employees, and agents from and of all claims, rights, expenses, debts, demands, costs, contracts, liability, obligations, actions, and causes of action of every nature, known or unknown, whether in law or equity, which I or my child-student had, now has, or may have which is in any way connected with, or arises out of the drug testing process of this policy. Printed Parent/Guardian Name Parent/Guardian Signature Date Parent/Guardian Contact Number

4 ATTACHMENT 2A CONSENT TO MANDATORY DRUG TESTING OF SAMPLES AND AUTHORIZATION FOR RELEASE OF INFORMATION (Adult Student) provisions of the drug testing program and agree to comply with the terms and conditions set forth by the policy. I hereby consent and authorize the School District to collect a testing sample from me and to have such sample tested for the presence of certain drugs and substances in accordance with the provisions of the policy. I further authorize the Superintendent of the School District or his/her designee to release the results of my drug testing sample in accordance with the policy, only when necessary, to the school principal, Athletic Director, head coach and/or advisor of any extracurricular/cocurricular activity in which I participate and/or members of the Student Assistance Program. I hereby acknowledge that this Consent shall remain valid unless and until I notify the Blue Mountain School District, by the completion of the proper forms, of my desire to be removed from the School District s drug testing program. I hereby release and discharge the School District and its directors, administrators, officers, employees, and agents from and of all claims, rights, expenses, debts, demands, costs, contracts, liability, obligations, actions, and causes of action of every nature, known or unknown, whether in law or equity, which I had, now have, or may have which is in any way connected with, or arises out of the drug testing process of this policy. *Printed Parent/Guardian Name *Parent/Guardian Signature Date *Parent/Guardian Contact Number *This signature is not required but is provided as a courtesy to parents/guardians of adult students to insure their knowledge of this agreement.

5 ATTACHMENT 3 DRUG TESTING PROGRAM WITHDRAWAL FORM (Minor) I hereby wish to withdraw my child-student from any and all extracurricular/cocurricular activities and parking privileges which require my child-student s participation in the Blue Mountain School District Drug Testing Program. I am completing and submitting this form to the Superintendent or his/her designee as acknowledgement for my desire to withdraw my child-student from all aspects of this program. My child-student s name will be withdrawn from the random testing pool on the date this form is received. Completing this will impact my child-student s participation in all extracurricular/cocurricular activities and/or parking privileges. I understand that by withdrawing my child-student, my child-student can no longer participate in any of the extracurricular/cocurricular programs or activities. My child-student may re-enter the testing pool after a period of one (1) calendar year from the date of this Withdrawal by completing a new Consent to Mandatory Drug Testing of Urine Samples and Authorization for Release of Information Form. STUDENTS HAVE 5 CALENDAR DAYS TO RECONSIDER THEIR DECISION AND RE- ENTER THE POOL WITH NO CONSEQUENCES. Printed Parent/Guardian Name Parent/Guardian Signature Date Printed School Designee Designee Signature Date Parking Privilege Number

6 ATTACHMENT 3A DRUG TESTING PROGRAM WITHDRAWAL FORM (Adult Student) I hereby wish to withdraw from any and all extracurricular/cocurricular activities and parking privileges which require my participation in the Blue Mountain School District Drug Testing Program. I am completing and submitting this form to the Superintendent or his/her designee as acknowledgement for my desire to withdraw from all aspects of this program. My name will be withdrawn from the random testing pool on the date this form is received. Completing this will impact my participation in all extracurricular/cocurricular activities and/or parking privileges. I understand that by withdrawing, I can no longer participate in any of the extracurricular/cocurricular programs or activities. I may re-enter the testing pool after a period of one (1) calendar year from the date of this Withdrawal by completing a new Consent to Mandatory Drug Testing of Urine Samples and Authorization for Release of Information Form. STUDENTS HAVE 5 CALENDAR DAYS TO RECONSIDER THEIR DECISION AND RE- ENTER THE POOL WITH NO CONSEQUENCES. *Printed Parent/Guardian Name *Parent/Guardian Signature Date Printed School Designee Designee Signature Date Parking Privilege Number *This signature is not required but is provided as a courtesy to parents/guardians of adult students to insure their knowledge of this agreement.

ADOPT-A-PARK AGREEMENT

ADOPT-A-PARK AGREEMENT The City of Perth Amboy Adopt-A-Park program is designed to increase community involvement in preserving our City parks. The program is voluntary and is designed for organizations,