JLCDA-E - Parent/Medical Provider Request to Administer Medical Marijuana at School

NEPN/NSBA Code:  JLCDA-E

MSAD #4 
PARENT/MEDICAL PROVIDER REQUEST TO 
ADMINISTER MEDICAL MARIJUANA AT SCHOOL 
Student’s Name: __________________________________________________________________

DOB: ________________ Note: Medical marijuana can only be administered at school or on a school bus to a student under the age of 18.

School: _________________________ Grade: _________ Teacher: _______________________

A. To be completed by Physician or Certified Nurse Practitioner:

Reason for use of medical marijuana: ____________________________________________

Form of medical marijuana: ____________________________________________________

Note: Medical marijuana may only be administered at school in non-smokeable form.

Dosage (amount): _________________________________________________________________

The medical marijuana must be administered during school hours:  _______  yes _______no

If yes, time to be administered: ______________________________________________________

Restrictions (including any restrictions on all school activities including sports for safety reasons) and/or important side effects 
________ none anticipated _______yes,  please describe in detail: _______________________________________________________________________________________________________________________________________________________________

Date Prescribed: __________________________________________________________________

Date to be discontinued: ____________________________________________________________

Any other necessary instructions or information: _________________________________________

NOTE: THE SCHOOL NURSE MAY CONTACT YOU IF THERE ARE FURTHER QUESTIONS CONCERNING THIS REQUEST.

Provider’s Signature: ________________________________ Date: ____________________

Printed Name: ________________________________________________________________

Address: ____________________________________________________________________

Phone Number: ____________________________ Fax Number: ___________________

Email Address: _____________________________________

Note: Any changes to the information above shall require a new request/permission form. 

B. To be completed by parent/guardian/legal custodian (designated “primary caregiver” under Maine law for medical use of marijuana purposes):

I understand and agree that if the school nurse has questions regarding the provider’s order, that the nurse may contact the child’s provider and obtain additional information about the medication. I give consent to the provider’s releasing that information.

I have read Board Policy JLCDA – Administration of Medical Marijuana in Schools to Students and understand that I must comply with all the requirements concerning the administration of medical marijuana.

Signature: ___________________________________________________________

Relationship: ___________________________________________________________

Date: ___________________________________________________________

NOTE: A COPY OF THE CURRENT WRITTEN CERTIFICATION FOR THE USE OF MEDICAL MARIJUANA MUST BE ATTACHED TO THIS FORM.

C. To be completed by school:

Date received: __________________ By whom: ___________________________________

Date reviewed: _________________ Reviewed by: _________________________________ 

Notes:______________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________


M.S.A.D. #4