Boulder Valley School District

JLCM- E-2

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  • Students
JLCM- E-2

File:  JLCM-E-2 (pdf)
Adopted:  June 13, 2023


PLAN FOR MEDICALLY NECESSARY TREATMENT AT SCHOOL

 

Student Name: _____________________________________________________________________________________________

Student ID # and Date of Birth: _________________________________________________________________________________

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

__________________________________________________________________________________________________________

 

Name and Contact Information for private health care specialist who will provide proposed medically necessary treatment on school district property

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

 

Treatment to be provided on District property:

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

 

Location:

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

 

Schedule:

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

 

__________________________________________________________________________________________________________
School Administrator                                                         Signature                                                                                      Date

__________________________________________________________________________________________________________
Parent/Guardian Name                                                    Signature                                                                                       Date

__________________________________________________________________________________________________________
Private Health Care Specialist                                          Signature                                                                                       Date