All Consent Fields Must Be Checked
DFCA Consent
I consent to the taking of specimens for drug screening as part of an examination in connection with enrollment into Drug Free Clubs of America (DFCA), and authorize the release of those results to DFCA and my parent or guardian. I also consent to the taking of, or school's release of my (or my child's) photograph, image and/or likeness to be used by and for program related purposes. *
Parent/Guardian authorization for consent verbiage above. *
Confirm Membership
Student Information:

Name:

Birthdate:

Homeroom #: n\a

School:

Graduation Year:

Gender:

Email:

Address:

Street:

City:

State:

Zip:

Parent/Guardian Information:

Name:

Email:

Phone:

Best Parent/Guardian #:

Best Student #:

Membership Information:

Selected:

Cost: Free