File:  JLCDB*-E

NOTE:  While Colorado school districts are not required by law to adopt an exhibit on this subject, this exhibit reflects legal requirements school districts must follow. This sample exhibit contains the policy content/language that CASB believes best meets the intent of the law. However, the district should consult with its own legal counsel to determine appropriate language that meets local circumstances and needs.

Administration of Medical Marijuana to Qualified Students

(Written Plan)

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 _____(name of school district)_____ 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 ______________.

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 or designee

                                                ___________________________________

                                                Signature of principal or designee

(Issue date)

COLORADO SAMPLE EXHIBIT 2016©