International Drug Free Youth (IDFY)
IDFY PARENTAL CONSENT - GENERAL RELEASE

Calcasieu Parish District Attorney, Rick Bryant The Pathology Lab

READ THIS DOCUMENT CAREFULLY, IT CONTAINS A RELEASE OF LIABILITY.

The Calcasieu Parish chapter of the International Drug Free Youth Program has been developed in connection with
the Calcasieu Parish District Attorney's Office and Lake Charles Memorial Hospital. The program has been
sanctioned by the Calcasieu Parish School Board and the Southwest Louisiana Mayor's Association. Its purpose is to
provide middle and high school students with a voluntary organization that rewards them for being drug-free and
influence those who abuse drugs to reject drugs through the use of positive peer pressure. Membership in IDFY is
gained through achieving drug-free results of a voluntary drug test, administered by Lake Charles Memorial Hospital.

Although specific test results will be kept confidential, results that show a student may have been taking illegal drugs
will be given to a professional counselor and may result in a student being unable to continue participation in the
program. If a student refuses a random retest a letter will be mailed to their parents advising them. A student who
fails a drug test may be readmitted at a later date if a drug retest shows he or she is drug-free.

Students age 14 and above will be notified privately should there be a confirmed positive test result. For students ages
13 and under, the parents will also be notified. Test results will not be used to develop any criminal prosecution.

Desiring to participate in the IDFY program [please circle one]:

We the undersigned parents / I the parent / I the managing conservator / I the legal guardian

of _________________________________ , age ______ , Social Security number ______________________ ,
give consent to collect and have tested a sample of urine at no charge to determine whether or not the student's system
is free from drug use. This also gives consent to subsequent random testing of the student to determine continued
qualification for the program. If a student refuses a random retest they will automatically be terminated from the IDFY
program and a parents will be notified.

As partial consideration for such testing, [please circle one] we / I release The Pathology Lab and its
employees from any and all liability and agree to indemnify and hold harmless these from any claim that might be made
by virtue of such test and the results thereof.

This release is intended to be a general release and release such persons and entities from any liability of claims,
including, but not limited to, claims or liability for personal injury, defamation, or invasion of privacy. The test
will not be given through this program to a person under the age of 18 years old without the consent of both the
individual and the parent or guardian.

Dated this _________________ day of ________________________________ , in 200 _____ .

Parent/legal guardian [Please print your name(s)]: ___________________________________________________

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Parent/legal guardian signature(s): ______________________________ _______________________________

Home Phone: __________________________ Work Phone: ________________________

Student signature: _______________________ School name: ________________________

List medication child has been prescribed:

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