Policy Manual

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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: __________________________

1. 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.  

2. 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. 

3. To be completed by school:

Date received: ____________________________ By whom: ______________________________________

Date reviewed: ___________________________ Reviewed by: ____________________________________

Notes: __________________________________________________________________________________

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*Please excuse any formatting errors.