STUDENT DRUG TESTING CONSENT FORM

Statement of Purpose and Intent

Participation in school sponsored extra-curricular activities at the Frederick Public School District is a privilege. Activity Students carry a responsibility to themselves, their fellow students, their parents, and their school to set the highest possible examples of conduct, which includes avoiding the use or possession of illegal drugs.

Drug use of any kind is incompatible with participation in extra-curricular activities on behalf of the Frederick Public School District. For the safety, health, and well being of the Frederick Public School District, the Frederick Public School District has adopted the attached Activity Student Drug Testing Policy and the Student Drug Testing Consent for use by all participating students at the middle school and high school levels.

Participation in Extra-Curricular Activities

Each Activity Student shall be provided with a copy of the Activity Student Drug Testing Policy and Student Drug Testing Consent, which shall be read, signed and dated by the student, parent or custodial guardian and coach/sponsor before such student shall be eligible to practice or participate in any interscholastic activities. The consent shall be to provide a urine sample: a) as part of their annual physical or for eligibility for participation; b) as chosen by the random selection basis; and c) at any time requested based on reasonable suspicion to be tested for illegal or performance-enhancing drugs. No student shall be allowed to practice or participate in any activity governed by the policy unless the student has returned the properly signed Student Drug Testing Consent.

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Student’s Last Name First Name MI

I understand after having read the “Student Activity Drug Testing Policy” and “ Student Drug Testing Consent,” that, out of care for my safety and health, the Frederick Public School District enforces the rules applying to the consumption or possession of illegal and performance-enhancing drugs. As a member of a Frederick extra-curricular interscholastic activity, I realize that the personal decision that I make daily in regard to the consumption or possession of illegal or performance-enhancing drugs may affect my health and well being as well as the possible endangerment of those around me and reflect upon any organization with which I am associated. If I choose to violate school policy regarding the use or possession of illegal or performance-enhancing drugs any time while I am involved in in-season or off-season activity I understand upon determination to that violation I will be subject to the restrictions on my participation as outlined in the Policy.

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Signature of Student Date

We have read and understood the Frederick Public School District “ Activity Student Drug Testing Policy”

And “ Student Drug Testing Consent.” We desire that the student named above participate in the extra-curricular interscholastic programs of the Frederick Public School District and we hereby voluntarily agree to be subject to its terms. We accept the method of obtaining urine samples, testing and analysis of such specimens, and all other aspects of the program. We further agree and consent to the disclosure of the sampling, testing and results as provided in this program.

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Signature of Parent or Custodial Guardian Date

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Signature of Coach Date