- J
- Students
File: JLCDB-E
Adopted: January 8, 2019
Revised: February 28, 2023
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FILLABLE FORM
BVSD Medical Marijuana Administration Plan
(Pursuant to Board Policy JLCDB)
To be completed by the parent/guardian:
Name of Qualified Student: ________________________________________________________________________________
School: _______________________________________________________ Grade: ______________________________
Name of Student’s “Primary Caregiver: _______________________________________________________________________
PhoneNumber for Student's Parent/Guardian/Primary Caregiver: ___________________________________________________
Person who will administer: _________________________________________________________________________________
Oil _____ Tincture _____ Edible Product _____ Other: ___________________________________________
Administration method used: ________________________________________________________________________________
Dosage Amount: ____________________________ Time(s) to be Administered: ____________________________________
Location of Administration: ____________________ Secured Storage Location: _____________________________________
By initialing the following statements and signing below, the undersigned parent/guardian acknowledges:
____ I have read and agree to comply with the procedure 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 grant permission for the designated volunteer school personnel to store, administer, or assist in the administration of medical marijuana to my child..
____ I understand that the district, with my input, will determine a designed 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 procedure on the administration of medical marijuana to qualified students or other policies.
____ I hereby release the Boulder Valley School District and its personnel from any legal claim which I have or may have arising out of the administration of medical marijuana to my child.
_________________________ _________________________________________________________
Date Signature of parent or guardian
BVSD Medical Marijuana Administration Plan
(Pursuant to Board Policy JLCDB
To be completed by the school
By initialing the following paragraphs and signing below, the undersigned school administrator acknowledges:
____ I have verified the qualified student’s current State of Colorado medical marijuana registration card has an expiration date of _________ and will maintain a copy of the registration card in the student’s records.
____ I have received input from the qualified student’s parent/guardian/primary caregiver on the plan.
____ I have determined the Qualified Student’s Administration Plan complies with Board Policy and may be implemented.
Date: _________________ Signature of Administrator: ___________________________________________
To be completed by the volunteer school personnel, if applicable:
By initialing the following paragraphs and signing below, the undersigned volunteer(s) acknowledges:
__________ I have read and agree to comply with the Board’s policy regarding the administration of medical marijuana to qualified students.
__________ I have read and understand the Student’s written plan for the administration of medical marijuana.
__________ I voluntarily agree to administer the student’s medical marijuana in accordance with the written plan.
Date: __________________ Signature of Volunteer(s): ______________________________________________
End of File: JLCDB-E