W<strong>ISD</strong> Random <strong>Student</strong> Drug Testing Permission Form (Grades 7‐12)*** YOU MUST COMPLETE AND RETURN THIS FORM TO YOUR CHILD'S CAMPUS ***School: Activity: Grade:<strong>Student</strong>'s Name (Print):<strong>Student</strong> ID (if known):We, ____________________________ as the parents or guardians <strong>of</strong> student, ____________________ acknowledge our childparticipates in extracurricular activities at <strong>Waller</strong> Independent School District and such is required to participate in the MandatoryRandom Drug Testing Program. We also acknowledge that our child will be participating in the Mandatory Random Drug TestingProgram if he/she applies for a parking permit at <strong>Waller</strong> High School.We understand and agree that participation in extracurricular activities and having a parking permit is a privilege that may bewithdrawn for violations <strong>of</strong> <strong>Waller</strong> <strong>ISD</strong> Policies.<strong>Waller</strong> Independent School District will be testing for the following drugs: Amphetamines, Barbiturates, Benzodiazepines,Marijuana, Cocaine, Ethanol, Xanax, Methadone, Opiates, Phencyclidine, Propoxyphene, and Steroids. The District shall reserve theright to test for any and all illegal or controlled substances as determined at the discretion <strong>of</strong> the District.We acknowledge that we have received a copy <strong>of</strong> the <strong>Waller</strong> <strong>ISD</strong> Local Policy on the Mandatory Random Drug Testing Program for<strong>Waller</strong> <strong>ISD</strong> extracurricular activities and receipt <strong>of</strong> a parking permit. We understand and agree that we are bound by all theprovisions in said program as it now exists and may hereafter, be amended. We have read and understand the drug testingprogram as set forth in the policy. We hereby consent and agree to the testing <strong>of</strong> our child as provided in said program. Weunderstand participation in extracurricular activities and receiving a parking permit at <strong>Waller</strong> <strong>ISD</strong> is conditioned upon the voluntaryconsent and participation <strong>of</strong> the drug testing policy.We grant permission for the Medical Review Officer to contact the student and parents if a drug test is positive. The purpose <strong>of</strong> thecontact with the Medical Review Officer is to find out if there is a potential reason that the Medical Review Officer should determinethe positive test to be negative. We are aware that the vendor/MRO will contact us in reference to a positive test.In consideration <strong>of</strong> the benefits afforded our child and us from this activity, we hereby grant permission for our child to participate inthis program. We further authorize the <strong>of</strong>ficers, employees, and agents <strong>of</strong> the lab W<strong>ISD</strong> chooses to use to communicate our child’sdrug/alcohol test results both orally and in writing to the <strong>Waller</strong> <strong>ISD</strong> designated administrators. We understand that thisinformation will not become part <strong>of</strong> the child’s medical record. We understand no physician/patient relationship is established bythe collection <strong>of</strong> this urine sample by the Certified Laboratory. We further release and discharge <strong>Waller</strong> <strong>ISD</strong>, its employees, trustees,and <strong>of</strong>ficials from any liability relating to the administration <strong>of</strong> the drug testing program. Also, we sign this release at our own freewill and without coercion.THIS IS A LEGAL CONSENT AND RELEASE FORM.PLEASE READ IT CAREFULLY AND BE SURE YOUR QUESTIONS HAVE BEEN ANSWERED BEFORE SIGNING.Executed this _____day <strong>of</strong> _____________, 201__ in <strong>Waller</strong>, Harris County, Texas.<strong>Parent</strong>/Guardian Signature<strong>Parent</strong>/Guardian SignatureDaytime Phone NumberDaytime Phone NumberI, the student mentioned above, acknowledge that I have read the foregoing consent and release and I understand it and agree to be bound by itsterms and the terms <strong>of</strong> the drug testing program.<strong>Student</strong> Signature <strong>Student</strong> ID DateIn the event that the student is over the age <strong>of</strong> 18 years, the student is agreeing to be contractually bound by the release as an adult.<strong>Student</strong> Signature<strong>Waller</strong> Independent School District Page 12 <strong>of</strong> 84 2012-2013 <strong>Parent</strong>/<strong>Student</strong> <strong>Handbook</strong> & <strong>Code</strong> <strong>of</strong> <strong>Conduct</strong>Date
W<strong>ISD</strong> <strong>Parent</strong> & <strong>Student</strong> Consent Checklist*** YOU MUST COMPLETE AND RETURN THIS FORM TO YOUR CHILD'S CAMPUS ***Check OneYesNoFormsAcceptable Use <strong>of</strong> the W<strong>ISD</strong> Electronic Communications Systems:All student computer use shall be in accordance with Board Policy CQ(LOCAL) and teacherdirectives. Inappropriate use <strong>of</strong> District computers and/or the Internet will result in denial orrestriction <strong>of</strong> the privilege to use the District’s computers and disciplinary consequences. Failureto check Yes will result in the student not being allowed in the library or the computer labs.For <strong>Student</strong>s: I have read the <strong>Parent</strong>/Guardian and <strong>Student</strong> Agreement for Acceptable Use <strong>of</strong>the W<strong>ISD</strong> Electronic Communication Systems. I understand that my computer use is not privateand that the District will monitor my activity on the computer system. I understand thatviolation <strong>of</strong> these provisions may result in suspension <strong>of</strong> my access to the system and otherpossible disciplinary actions.For <strong>Parent</strong>s/Guardians: I have read the <strong>Parent</strong>/Guardian and <strong>Student</strong> Agreement for AcceptableUse <strong>of</strong> the W<strong>ISD</strong> Electronic Communication Systems. In consideration for the privilege <strong>of</strong> my childusing the technology resources <strong>of</strong> <strong>Waller</strong> <strong>ISD</strong> which includes internet access and videoconferencing, I hereby release the District, its operators and any institutions with which they areaffiliated from any and all claims and damages <strong>of</strong> any nature arising from my child’s use <strong>of</strong>, orinability to use, the Internet and District Network System.YesNo<strong>Student</strong> Computer Use Contract: I have read, understand, and will adhere to the responsibilitiescited in the <strong>Waller</strong> <strong>ISD</strong> Computer User Contract. Failure to check Yes will result in the student notbeing able to use <strong>Waller</strong> <strong>ISD</strong> computer equipment. Refer to page 12 in the W<strong>ISD</strong> <strong>Student</strong>/<strong>Parent</strong><strong>Handbook</strong>.<strong>Student</strong>’s Name & Signature:Printed Name:<strong>Student</strong> ID:Date:Signature:<strong>Parent</strong>/Guardian’s Name & Signature:Printed Name:Date:Signature:<strong>Waller</strong> Independent School District Page 13 <strong>of</strong> 84 2012-2013 <strong>Parent</strong>/<strong>Student</strong> <strong>Handbook</strong> & <strong>Code</strong> <strong>of</strong> <strong>Conduct</strong>