Leeds City Schools
School-based Student Random Drug and Alcohol Testing Program Pupil Consent to Test Form
I understand fully that my performance as a pupil and the reputation of my school are dependent, in part, on my conduct as an individual. I hereby agree and abide by the standards, rules, and regulations set forth by the Leeds City Board of Education and sponsors-coaches for the activity in which I participate. I authorize the Leeds City Schools to conduct a test on saliva or urine which I provide onsite to test for alcohol and/or drug use if my number is drawn from the random pool. Pursuant to the regulations for the Students Random Drug and Alcohol Testing Policy and Implementing Guidance, I also authorize the release of information concerning the results of such tests to designated personnel. I understand that this form remains in effect until the submission of an Activity Drop Form or graduation and/or withdrawal from the school district.
Pupil Name
Current Grade
Pupil ID (leave blank)
Pupil Signature
Date
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Month
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Day
Year
Date
Parent/Guardian Name
Parent/Guardian Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Signature
Date
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Month
-
Day
Year
Date
Submit
Should be Empty: