Participant Agreement and Consent to Drug And/Or Alcohol Testing

I hereby agree, upon a request made under the drug/alcohol testing policy of The Up Foundation, to submit to a drug or alcohol test and to furnish a sample of my urine, breath, and/or blood for analysis. I further authorize and give full permission to have The Up Foundation and/or its representative to send the specimen or specimens so collected to a laboratory for screening test for the presence of any prohibited substances under the policy, and for laboratory or other testing facility to release any and all documentation relating to such test to The UP Foundation and/or to any governmental entity involved in a legal proceeding or investigation connected with the test.

I understand that only duly-authorized personnel of The UP Foundation will have access to information furnished or obtained in connection with the test; that they will maintain and protect the confidentiality of such information to the greatest extent possible; and that they will share such information only to the extent necessary to make treatment decisions and to respond to inquiries or notices from government entities.

I will hold harmless The UP Foundation, its representing company, and any testing laboratory The UP Foundation might use, meaning that I will not sue or hold responsible such parties for any alleged harm to me that might result from such testing, including loss of employment or any other kind of adverse action that might arise as a result of the drug or alcohol test, even if a drug company or laboratory representative makes an error in the administration or analysis of the test or the reporting of the results. I will further hold harmless The UP Foundation and any testing laboratory The UP Foundation might use for any alleged harm to me that might result from there lease or use of information or documentation relating to the drug or alcohol test, as long as there lease or use of the information is within the scope of this policy and the procedures as explained in the paragraph above.

This policy and authorization have been explained to me in a language I understand, and I have been told that if I have any questions about the test or the policy, they will be answered.

I UNDERSTAND THAT THE UP FOUNDATION WILL REQUIRE A DRUG SCREENAND/OR ALCOHOL TEST UNDER THIS POLICY WHENEVER I AM INVOLVED INTREATMENT, INDIVIDUAL COUNSELING, GROUP COUNSELING OR INJURY UNDERCIRCUMSTANCES THAT SUGGEST POSSIBLE INVOLVEMENT OR INFLUENCE OFDRUGS OR ALCOHOL IN THE ACCIDENT OR INJURY EVENT, AND I AGREE TO SUBMIT TO ANY SUCH TEST.