Boulder Valley School District

JLCDB-E

  • J
  • Students
JLCDB-E

File: JLCDB-E
Adopted:  January 8, 2019
Revised: February 28, 2023

Click to fill out our 
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