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I hereby consent to the taking of a urine sample to be used fora drug screening test (a “sample”). I specifically authorize collection and screening of my sample(s). I have been informed and understand that I retain the express right to stop the taking of the sample and/or testing of my sample(s) at any time and that I may leave the room at any time.

I hereby authorize and direct the release of my test results to my school, Reitz Memorial High School, or an authorized agent thereof.

I understand that this authorization to release screening test results will remain in effect unless revoked in writing and that I may revoke this authorization at any time (except to the extent that action has been taken in reliance thereon), but that in no event may the release from liability be revoked or nullified in any manner.

By signing this consent and in consideration for the agreement to perform the drug screening test at no cost to the undersigned, I agree to forever release and hold harmless the Catholic Diocese of Evansville and Reitz Memorial High School from any and all liability whatsoever arising from collecting my sample(s) and releasing the results of my drug screening test to the above-named school. I further specifically agree to relinquish any and all rights to privacy I may have with regard to the release of my results of my drug screening test to the Principal or Principal’s designee as per the Reitz Memorial High School Drug, Alcohol, and Tobacco Use and Testing Policy.

 

Please Note: Throughout the document, the term "minor" refers to ALL Reitz Memorial students. The following form must be signed by BOTH a parent/guardian and each student, regardless of if the child is over 18 years of age.

The term "minor" refers to all Reitz Memorial students. The following form must be completed by parents for all students, even if over 18 years of age. Please select the number of students for which you are completing the Student/ Parent Handbook Signature Page:
Minor
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First Participant's Name

First Name*

Middle Name

Last Name*
First Participant's Date of Birth*
First Participant's Class Year
First Participant's Signature*
Parent or Guardian's Email Address

Email*

Confirm Email*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*
Parent or Guardian's Date of Birth*
Parent or Guardian's Class Year
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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