File: JLCDB-E (pdf)
Adopted: January 8, 2019
Medical Marijuana Administration Plan
To be completed by the parent/guardian:
Name of Qualified Student1: ___________________________________________________________________
School: _______________________________________________________ Grade: ___________________ Name of
Student’s “Primary Caregiver”2: _________________________________________________________
Primary Caregiver’s phone: ____________________________________________________________________
Permissible form3 of medical marijuana to be administered:
Oil ___ Tincture ___ Edible Product ___ Other: ___
Administration method to be used: _____________________________________________________________
Dosage Amount: ____________________________ Time(s) to be Administered: ______________________
Location of Administration4: __________________________________________________________________
By initialing the following statements and signing below, the undersigned parent/guardian hereby 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 understand that as soon as I or my designated primary caregiver complete the medical marijuana administration, I or my primary caregiver must remove any remaining medical marijuana from the ground of the school, district, school bus, or school-sponsoredevent.
____ 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.
By signing below, I hereby release the Boulder Valley School District and its personnel from any legal claim which I now have or may hereafter have arising out of the administration of medical marijuana to my child.
Signature of parent or guardian Date
BVSD Medical Marijuana Administration Plan
To be completed by the school
I have reviewed a copy of the student’s registration from the state of Colorado authorizing the student to receive medical marijuana. The expiration date is: ___________________
After receiving input from the student’s parent/guardian, I have conditionally approved the student’s identified primary caregiver to administer the permissible form of medical marijuana in the designated location – both identified above.
Name and Signature of Nurse: ________________________________________________________________
Name and Signature of Administrator: __________________________________________________________
A copy of the current registration card will be maintained in the student’s health file and updated as needed.
Provide copies of the Administration Plan and distribute to:
- Primary Caregiver (if different than parent/guardian)
- School Principal
- School Nurse
1 “Qualified Student” means a student who holds a valid registration from the state of Colorado for the use of medical marijuana and for whom the administration of medical marijuana cannot reasonably be accomplished outside of school hours.
2 “Primary Caregiver” means the qualified student’s parent, guardian or other responsible adult over 18 years of ago who is identified on the student’s Registry identification card. In no event shall another student be recognized as a primary caregiver.
3 “Permissible Form” of medical marijuana means non-smokeable products such as oils, tinctures, edible products or lotions that can be administered and fully ingested or absorbed in a short period of time. Other non-smokeable forms may be approved on a case by case basis.
4 “Designated location” means a location identified in writing by the school district in its sole discretion and may include a location on the grounds of the school in which the student is enrolled, upon a school bus in Colorado, at a school-sponsored event in Colorado or on other District Property.
End of File: JLCDB-E