RISE Charter School’s Extracurricular Activity Consent Form
I have received and have read and understand a copy of the RISE Charter School’s Policy 3400 “Extracurricular Activities Drug-Testing Program”. I desire that _____________________ participate in this program and in the extracurricular program of RISE Charter School 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____
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Student Signature Parent/Guardian Signature
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I, _________________________________, have decided not to participate in any extracurricular activities sponsored by RISE Charter School 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.
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Student Signature Date
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Parent/Guardian Signature Date