Boulder Valley School District

JLCM- E-1

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  • Students
JLCM- E-1

File:  JLCM-E-1 (pdf)
Adopted:  June 13, 2023


REQUEST FOR MEDICALLY NECESSARY TREATMENT AT SCHOOL

 

Student Name: _____________________________________________________________________________________________

Student ID # and Date of Birth: _________________________________________________________________________________

Parent/Guardian Name(s) & telephone number: ____________________________________________________________________

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Name, Colorado License #, Address, and Telephone Number of qualified health care provider writing prescription for medically necessary treatment on District property

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Name, Colorado License #, certification, or authorization, Address, and Telephone Number of private health care specialist who will provide proposed medically necessary treatment on school district property

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Describe in detail the proposed treatment to be provided on District property during the school day (location, time of day, services to be provided):

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By signing this Request, parent(s)/guardian(s) agrees to sign a medical release authorizing the school district to confer with the qualified health care provider to obtain follow-up information about the student’s medical needs and the medically necessary treatment.

By signing this Request, parent(s)/guardian(s) acknowledges their sole financial responsibility for the services.

By signing this Request, parent(s)/guardian(s) waive liability of any and all claims against the District for any negligence, intentional conduct, malpractice, or other misconduct on the part of the Provider, including claims arising from the conduct of the Provider under the Claire Davis School Safety Act, C.R. S. § 24-10-106.3, and C.R.S. § 13-20-1201 et. seq., Actions for Sexual Misconduct Against Minors.

By signing this Request, parent(s)/guardian(s) Parents/Guardians agree to waive any claims for a Free Appropriate Public Education under the Individuals with Disabilities Act (“IDEA”) to the extent that the rendering of services by the Provider interferes or restricts any required educational or related services under the Student’s current IEP.

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Parent/Guardian Name                                                    Signature                                                                                       Date

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Parent/Guardian Name                                                    Signature                                                                                       Date

 

Attach a copy of the Student’s prescription, recommendation or order.