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Policy JLCDA-R
Maine law provides that a “primary caregiver” (defined as parent, guardian or legal custodian under Maine’s medical marijuana law, 22 MRSA § 2423-A91)(E)) may possess and administer marijuana in a non-smokeable form in a school bus or on the grounds of the preschool or primary or secondary school in which a minor qualifying patient is enrolled, if: a) a medical provider has provided the minor qualifying patient with a current written certification for the medical use of marijuana and b) possession of medical marijuana is for the purpose of administering it to the minor qualifying patient. In accordance with applicable law, this only applies to students under the age of 18. Students 18 years of age or older may not use 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: __________________________
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 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 ADMINISTRATOR OR HIS/HER DESIGNEE 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.
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 administrator has questions regarding the provider’s order, that he/she or their designee may contact the child’s provider and obtain additional information about the medication. I consent to the provider releasing that information.
I have read Board Policy JLCD – Administering Medical Marijuana to Students and understand that I must comply with all the requirements concerning the administration of medical marijuana.
Signature: ________________________________ Relationship: __________________________________
Primary Caregiver
Signature: ________________________________ Relationship:___________________________________
Primary Caregiver
Date: ____________________________________
NOTE: A COPY OF THE CURRENT WRITTEN CERTIFICATION FOR THE USE OF MEDICAL MARIJUANA MUST BE ATTACHED TO THIS FORM.
To be completed by school:
Date received: ____________________________ By whom: ______________________________________
Date reviewed: ___________________________ Reviewed by: ____________________________________
Notes: __________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
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*Please excuse any formatting errors.
