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Administration of Medical Marijuana to Qualified Students (Written Plan): JLCDB-E

  • Students: J
Administration of Medical Marijuana to Qualified Students (Written Plan): JLCDB-E
Updated

To be completed by the student’s parent or guardian

Name of qualified student ______________________________________________

School _____________________________________________ Grade __________

Name of student’s primary caregiver ______________________________________

Primary caregiver’s phone ______________________________________________

Permissible form of medical marijuana to be administered to the qualified student by the student’s primary caregiver ______________________________________________________________________________________________________________________________________________________________________________________________________________________

Administration method to be used by the student’s primary caregiver (to assist the school district in determining an appropriate location for administration of medical marijuana to the student) ____________________________________________________________ ___________________________________________________________________

Dosage amount ______________________________________________________

Proposed times to administer ___________________________________________

By initialing the following paragraphs and signing below, the undersigned parent or guardian hereby acknowledges:

_____ I have read and agree to comply with the board’s policy regarding the administration of medical marijuana to qualified students.

_____ I assume all responsibility for the provision, administration, maintenance and use of medical marijuana to my child.

_____ I understand that as soon as I or my designated primary caregiver complete the medical marijuana administration, I or my designated primary caregiver must remove any remaining medical marijuana from the grounds of the school, district, school bus or school sponsored event.

_____ I understand that the district, with my input, will determine a designated location and any protocols regarding the administration of medical marijuana to my child and that this plan does not allow for the administration of medical marijuana on federal property or any location that prohibits marijuana on its property.

_____ I understand that permission to administer medical marijuana in accordance with this plan may be revoked for the failure to comply with the board’s policy on the administration of medical marijuana to qualified students or other applicable board policies.

By signing below, I hereby release the School District 27J and its personnel from any legal claim which I now have or may hereafter have arising out of the administration of medical marijuana to my child.

Date ________________

___________________________________
Signature of parent or guardian

___________________________________
Signature of qualified student (if capable)

To be completed by the school

[ ] I have reviewed a copy of the student’s registration from the state of Colorado authorizing the student to receive medical marijuana. The expiration date is _____________.

[ ] I have reviewed a copy of the relevant medical records provided by the student’s physician indicating a need for the administration of medical marijuana during the student’s school day and/or activity.

[ ] After receiving input from the student’s parent or guardian, I have conditionally approved the student’s identified primary caregiver to administer the permissible form of medical marijuana identified above in the following designated location(s): ______________________________________________________________________________________________________________________________________________________________________________________________________________________

Such administration shall occur in accordance with the following protocol(s): ______________________________________________________________________________________________________________________________________________________________________________________________________________________

Date ________________

_______________________________
Name of principal

_______________________________
Signature of principal