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

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I, _________________________________, have decided not to participate in any extracurricular activities

sponsored by Jerome Joint 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 urinalysis.

________________________________________ _______________

Student Signature Date

________________________________________ _______________

Parent/Guardian Signature Date