Individual Health Care Plan

Please complete all fields marked (*)

Your first name *

Your last name *

Your email *

Child's Name *

Child's Class *

Date of Birth *

Child's Address *

Medical Diagnosis or Condition *

Name *

Family Contact Information

Relationship to Child *

Mobile Number *

Work Number

Name

Clinic/Hospital Contact

Phone Number

GP Name *

GP Phone Number *

Describe medical needs. *

Give details of child's symptoms, triggers, signs, treatments, facilities, equipment or devices, environmental issues etc

Name of medication *

Name of medication, dose, method of administration, when to be taken, side effects, contra-indications, administered by/self-administered with/without supervision *

Daily care requirements

Specific support for the pupil's educational, social and emotional needs

Arrangements for school visits/trips etc

Other information

Describe what constitutes an emergency, and the action to take if this occurs

Please provide a signature. *

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Individual Health Care Plan