Drug/Alcohol Declaration

I, _____________________________________________, am not habituated or addicted to depressants, stimulants, narcotics, alcohol

or other substances nor do I have a physical or emotional condition that may alter my behavior, interfere with the performance of my

duties or pose a potential risk to patients. The responses above are true to the best of my knowledge. I understand that any omissions,

error and/or misstatement of facts may be grounds for termination of my Bright Future for the Children LLC contract/employment.

I hereby acknowledge that I have read and understand the foregoing information and that my signature below signifies my agreement to comply with the above terms. In the event of a breach or threatened breach of the Drug/Alcohol Declaration, I acknowledge that Bright Future for the Children may, as applicable and as it deems appropriate, pursue disciplinary action up to and including my termination from Bright Future for the Children.

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