Cut Bank School District 3350F

STUDENTS

EXTRACURRICULAR ACTIVITIES DRUG TESTING PROGRAM
CONSENT FORM

I have received and have read and understand a copy of the Cut Bank Public Schools’ “Extracurricular Activities Drug-Testing Program” policy. I desire that ____________________________________________________________ participate in this program and in the extracurricular programs of Cut Bank High 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 and/or saliva specimens, testing, and analyses of such specimens and all other aspects of the program. I agree to cooperate in furnishing urine and/or saliva 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 Privacy 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.

___________________________________ ___________________________________
Student Signature Parent/Guardian Signature

___________________________________ ___________________________________
Date Date

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I, ____________________________________________________________________________, have decided not to participate in any extracurricular activities sponsored by Cut Bank High School for the remainder of this school year. In order for me to participate in the extracurricular activities program at a later date, I understand that I must submit either urine or saliva samples.

___________________________________ ___________________________________
Student Signature Parent/Guardian Signature

___________________________________ ___________________________________
Date Date

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