Form 4.24A
RANDOM DRUG TEST CONSENT
Printed student name ___________________________________________
Smackover Public Schools believes that all students should be drug free. To help insure this, the District
requires each student who participates in extra-curricular or co-curricular activities to submit to random
drug testing as outlined in Policy 4.24A. If your child wishes to participate in any activity sponsored by
Smackover High School, you must consent to participate in the random drug testing program.
I/We, the parent(s) of the above named student do hereby consent to participate in and abide by and
comply with the provisions of Policy 4.24A - Chemical Screen Testing for Smackover High School
Students for Activity Participation.
Printed parent’s name(s)________________________________________________________________
Parent’s signature _________________________________________ Date ___________________
I, the above named student of Smackover High School, do hereby consent to participate in and abide by
and comply with the provisions of Policy 4.24A - Chemical Screen Testing for Smackover High School
Students for Activity Participation.
Student’s signature ________________________________________ Date ___________________
NOTE: REFUSAL TO SIGN THIS CONSENT FORM WILL PROHIBIT YOUR CHILD FROM
PARTICIPATION IN ALL EXTRACURRICULAR/CO-CURRICULAR ACTIVITIES
SANCTIONED BY SMACKOVER HIGH SCHOOL
Date filed ____________________________________________
(To be filled in by office personnel)
Random number assigned this student for School Year 2013-2014 __________________
