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

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

<table cellpadding="0" cellspacing="0" class="t1" id="bkmrk-a.-to-be-completed-b" style="height: 847px; border-style: solid; border-color: black;"><tbody><tr style="height: 35px;"><td class="td1" style="height: 35px; width: 809px;" valign="top">***A. To be completed by Physician, Physician Assistant or Certified Nurse Practitioner***

</td></tr><tr style="height: 35px;"><td class="td2" style="height: 35px; width: 809px;" valign="top">Student’s Name: <span class="Apple-converted-space">                           </span>

</td></tr><tr style="height: 35px;"><td class="td3" style="height: 35px; width: 809px;" valign="top">Birth date: <span class="Apple-converted-space">                                            </span>School:

</td></tr><tr style="height: 35px;"><td class="td2" style="height: 35px; width: 809px;" valign="top">Teacher:

</td></tr><tr style="height: 35px;"><td class="td3" style="height: 35px; width: 809px;" valign="top">Grade:

</td></tr><tr style="height: 80px;"><td class="td4" style="height: 80px; width: 809px;" valign="top">Reason for use of medical marijuana:

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

</td></tr><tr style="height: 35px;"><td class="td3" style="height: 35px; width: 809px;" valign="top">Form of medical marijuana:

</td></tr><tr style="height: 35px;"><td class="td2" style="height: 35px; width: 809px;" valign="top">***Note:<span class="Apple-converted-space"> </span>Medical marijuana may only be administered at school in non-smokable form***

</td></tr><tr style="height: 35px;"><td class="td3" style="height: 35px; width: 809px;" valign="top">Dosage (amount):

</td></tr><tr style="height: 57px;"><td class="td4" style="height: 57px; width: 809px;" valign="top">The Medical marijuana <span style="text-decoration: underline;"><span class="s1">must</span></span> be administered during school hours.<span class="Apple-converted-space"> </span>

<span class="s2">Please circle:<span class="Apple-converted-space">  </span>YES<span class="Apple-converted-space">  </span>or<span class="Apple-converted-space">  </span>NO<span class="Apple-converted-space">      </span>If yes, specific time to be administered: \_\_\_\_\_\_\_\_</span>

</td></tr><tr style="height: 124px;"><td class="td5" style="height: 124px; width: 809px;" valign="top">Restrictions (including any restrictions on school activities for safety reasons) and/or important side effects. Please check a box below.

<span class="s3">( ) </span>No restrictions anticipated

<span class="s3">( ) </span>Yes, restrictions – please describe in detail:

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

</td></tr><tr style="height: 35px;"><td class="td3" style="height: 35px; width: 809px;" valign="top">Date medical marijuana prescribed:

</td></tr><tr style="height: 35px;"><td class="td2" style="height: 35px; width: 809px;" valign="top">Date medical marijuana to be discontinued:

</td></tr><tr style="height: 57px;"><td class="td6" style="height: 57px; width: 809px;" valign="top">Any other necessary instructions or information:

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

</td></tr><tr style="height: 55px;"><td class="td7" style="height: 55px; width: 809px;" valign="top">***Note: The school nurse may contact you if there are further questions concerning this request.<span class="Apple-converted-space">  </span>Any changes to the information shall require a new request form.***

</td></tr><tr style="height: 124px;"><td class="td8" style="height: 124px; width: 809px;" valign="top">*Provider’s signature: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_*

*Printed name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_*

*Address: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_*

*Email: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_*

<span class="s2">*Phone: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Fax: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_*</span>

</td></tr></tbody></table>

<table cellpadding="0" cellspacing="0" class="t1" id="bkmrk-b.-to-be-completed-b" style="border-style: solid; border-color: black;"><tbody><tr><td class="td1" valign="top">***B. To be completed by parent/guardian/legal custodian:***

</td></tr><tr><td class="td9" valign="top">*<span class="Apple-converted-space"> </span>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.<span class="Apple-converted-space"> </span>I consent to the provider releasing that information. <span class="Apple-converted-space">   </span>*

*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.*

<span class="Apple-converted-space"> </span>

***Parent/Guardian/Legal Custodian signature required.***

***Signature: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date: \_\_\_\_\_\_\_\_\_\_\_\_\_***

***Printed name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_***

***Relationship: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_***

***Phone: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_***

***The following caregiver has been designated to administer marijuana to the student.<span class="Apple-converted-space"> </span>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.***

***<span class="Apple-converted-space"> </span>***

***Name of Designated Caregiver***: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

<span class="Apple-converted-space"> </span>

***Relationship to Student***: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

<span class="s1">***NOTE***</span>***: COPIES OF THE FOLLOWING MUST BE ATTACHED TO THIS FORM:***

***<span class="Apple-converted-space"> </span>***

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.

<span class="s5"><span class="Apple-converted-space"> </span></span>

</td></tr><tr><td class="td10" valign="top">***Note: A copy of the current written certification for the use of medical marijuana must be attached to this form.***

</td></tr><tr><td class="td3" valign="top"><span class="s2">***C. To be completed by the school***</span>***:***

</td></tr><tr><td class="td11" valign="top">***Date request form received: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_***

***Received by: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_***

***Date request form reviewed: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_***

***Reviewed by: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_***

<span class="s2">***Please circle, the request has been:<span class="Apple-converted-space"> </span>Approved or Not Approved***</span>

</td></tr></tbody></table>

<span class="Apple-converted-space"> </span>

Adopted:<span class="Apple-converted-space"> </span>February 28, 2018

Policy Reviewed/Revised: October 20, 2021