JLCDA-E1 - Medical Marijuana Parent/Provider Request Form to Administer at School

A. To be completed by Physician, Physician Assistant or Certified Nurse Practitioner

Student’s Name:                            

Birth date:                                             School:

Teacher:

Grade:

Reason for use of medical marijuana:

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Form of medical marijuana:

Note: Medical marijuana may only be administered at school in non-smokable form

Dosage (amount):

The Medical marijuana must be administered during school hours. 

Please circle:  YES  or  NO      If yes, specific time to be administered: ________

Restrictions (including any restrictions on school activities for safety reasons) and/or important side effects. Please check a box below.

( ) No restrictions anticipated

( ) Yes, restrictions – please describe in detail:

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Date medical marijuana prescribed:

Date medical marijuana to be discontinued:

Any other necessary instructions or information:

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Note: The school nurse may contact you if there are further questions concerning this request.  Any changes to the information shall require a new request form.

Provider’s signature: ____________________________ Date: ______________

Printed name: _____________________________________________________

Address: __________________________________________________________

Email: ___________________________________________________________

Phone: _________________________ Fax: ______________________________

B. To be completed by parent/guardian/legal custodian:

 I understand and agree that if the school nurse has questions regarding the provider’s order, that the nurse may contact the child’s provider and obtain additional information about the medication. I consent to the provider releasing that information.    

I have read Board policy JLCDA-Medical Marijuana in Schools and understand that I must comply with all the requirements concerning the administration of medical marijuana.

Parent/Guardian/Legal Custodian signature required.

Signature: ______________________________________ Date: _____________

Printed name: _____________________________________________________

Relationship: ______________________________________________________

Phone: _____________________________________________________________

The following caregiver has been designated to administer marijuana to the student. This caregiver has obtained the required registry identification card. If the designated caregiver is not a parent/legal guardian/legal custodian, he/she has the required authorization from the State that he/she is authorized to administer marijuana to a student on school grounds.

Name of Designated Caregiver: ________________________________________

Relationship to Student: _______________________________________________

NOTE: COPIES OF THE FOLLOWING MUST BE ATTACHED TO THIS FORM:

1. Current written certification for the use of medical marijuana by the student.

2. The state caregiver designation form.

3. The designated caregiver’s registry identification card.

4. If the designated caregiver is not a parent/legal guardian/legal custodian of the student, documentation that the caregiver has is authorization by the state to administer marijuana to a student on school grounds.

Note: A copy of the current written certification for the use of medical marijuana must be attached to this form.

C. To be completed by the school:

Date request form received: __________________________________________

Received by: ___________________________________________________________

Date request form reviewed: __________________________________________

Reviewed by: ___________________________________________________________

Please circle, the request has been: Approved or Not Approved