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Student consent to perform
urinalysis for drug / alcohol testing...
I hereby consent to
have my urine collected and tested for the presence of drugs or alcohol in
accordance with the Pickerington Drug and Alcohol Testing Policy for Student
Athletes.
I understand that
this testing will occur according to the guidelines of the Pickerington Drug and
Alcohol Testing Policy for Student Athletes.
I understand that my urine samples taken for drug / alcohol testing will be sent only to a
certified medical laboratory for actual testing.
I hereby give my
consent for the medical laboratory selected by the Pickerington Board of
Education, its doctors, employees, or agents, together with any clinic,
hospital, or laboratory designated by the selected medical laboratory, to
perform urinalysis testing on me, for the detection of drugs / alcohol.
I further give my
permission to the medical laboratory selected by the Pickerington Board of
Education, its doctors, employees, or agents, to release all results of these
tests to designated School District employees or agents. I understand that
these results will also be made available to me and to my parent(s) / guardian(s).
I hereby authorize
the release of the results of such testing to my parent(s) / guardian(s).
THIS FORM MUST BE
ACCOMPANIED BY A PARENT / GUARDIAN CONSENT FORM.
I hereby release,
waive, and discharge the Pickerington Board of Education, its individual
members, employees, agents and anyone acting on its behalf from any and all liability
claims, or causes of action arising from or related to the urinalysis drug /
alcohol testing for the athletic participation and / or the release of related
information as authorized in this form and in the Drug and Alcohol Testing Policy
for Student Athletes.
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Student Athlete
Signature
Date
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