Jerome Joint School District No. 261

STUDENTS 3400F

EXTRACURRICULAR CONSENT FORM

I have received and have read and understand a copy of the Jerome Joint School District’s “Extracurricular Activities Drug-Testing Program”.  I desire that _________________________ participate in this program and in the extracurricular program of Jerome Joint School District and hereby voluntarily agree to be subject to its terms for the entire high school career (grades 9-12).  I accept the method of obtaining urine specimens, testing, and analyses of such specimens and all other aspects of the program.  I agree to cooperate in furnishing urine specimens that may be required from time to time.

I further agree and consent to the disclosure of the sampling, testing, and results provided for this program.  This consent is given pursuant to all State and Federal Statutes and is a waiver of rights to nondisclosure of such test records and results only to the extent of the disclosures in the program.

Date: ______________, 20__

____________________________________       ____________________________________

Student Signature Parent/Guardian Signature