CONSENT TO PERFORM URINALYSIS FOR DRUG TESTING

We hereby consent to allow the student named on the front of this form to undergo urinalysis testing for the presence of illicit drugs or banned substances in accordance with the Policy and Procedure for Random Urine Drug Testing of Heath City School District Student Participating in Interscholastic Sports as approved by the heath City School Board.

We understand that a qualified vendor will oversee the collection process.

We understand that any urine samples will be sent only to a certified medical laboratory for actual testing, and that the samples will be coded to provide confidentiality.

We hereby give our consent to the medical vendor selected by the Heath City School Board, their laboratory, doctors, employees, or agents, together with any clinic, hospital, or laboratory designated by the selected medical vendor to perform urinalysis testing for the detection of illicit drugs or banned substances.

We further give permission to the medical vendor selected by the Heath City School Board, its doctors, employees, or agents, to release all results of these tests to the Medical Review Officer (MRO) working for the medical vendor.

We understand these results will be forwarded to the Building Principal and will also be made available to us. We understand that consent pursuant to this Informed Consent Agreement will be effective for all athletic sports in which this student athlete might participate during the current school year.

We hereby release the Heath City Schools Board of Education and its employees from any legal responsibility or liability for the release of such information and records.

This will be deemed a consent pursuant to the Family Educational Rights and Privacy Act of 1974, 20 U.S.C. 1232g as amended, and Ohio Revised Code 3319.321, for the release of the test results as authorized by this Informed Consent Agreement or as required by law.

READ ATHLETIC CODE OF CONDUCT AND EXPECTATIONS AND SIGN!

HEATH CITY SCHOOLS INFORMED CONSENT AGREEMENT

Student Name _________________________________________ Grade _______________

(Please Print)

AS A STUDENT:

I understand and agree that participating in athletic activities is a privilege that may be withdrawn for violation of the Athletic Code of Conduct and Expectations, hereinafter Code of Conduct.

I have read the Code of Conduct and thoroughly understand the consequences that I will face if I do not honor my commitment to the Code of Conduct.

I understand and realize that there is risk of injury in participating in athletic activities.

I understand that when I participate in any athletic program, I will be subject to initial and random urine drug testing, and if I refuse, I will not be allowed to practice or participate in any athletic activities. I have read the consent on the reverse of this form and agree to its terms.

I understand this is binding while a student at Heath City Schools.

____________________________________________________ Date ________________

Student Signature

AS A PARENT/GUARDIAN/CUSTODIAN:

I have read the Code of Conduct and understand the responsibility of my son/daughter/ward as a participant in athletic activities in the Heath City Schools.

I pledge to promote healthy lifestyles for all student athletes of the Heath City Schools.

I understand and realize that there is an assumed risk of injury involved for my son/daughter/ward as a participant in athletic activities.

I understand that my son/daughter/ward, when participating in any athletic program, will be subjected to initial and random urine drug testing, and if they refuse, will not be allowed to practice or participate in any athletic activities. I have read the consent on the reverse of this form and agree to its terms.

I understand this is binding while my son/daughter/ward is a student at Heath City Schools.

_________________________________________________ Date ________________

Parent/Guardian/Custodian Signature

_______________________________ __________________ ____________________

Parent/Guardian/Custodian Name (Print) Home Phone Work Phone

______________________________________________________________________

Address

Please list any medications that your son/daughter ward has taken within the last 30 days:

_________________________________________________________________________

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