File: JLCDB-E - Administration of Medical Marijuana to Qualified Students - Written Plan - Exhibit File: JLCDB-E - Administration of Medical Marijuana to Qualified Students - Written Plan - ExhibitTo 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 _________________________
Provide written consent from the medical care provider or doctor.
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 Summit 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
Adopted October 6, 2016