Healthcare Plan for a Pupil with Medical Needs

Name Tutor Group Date of Birth Condition Allergies Date Review Date

Contact Information

Family Contact 1

Name Phone number (work) Phone number (home) Relationship

Family Contact 2

Name Phone number (work) Phone number (home) Relationship

Clinic / Hospital contact

Name Phone Number

G.P.

Name Phone number Describe condition and give details of pupil's individual symptoms

Daily care requirements (e.g. before sport/ at lunchtime) Describe what constitutes an emergency for the student, and the action to take if this occurs and by who: Follow up care

Request for School Staff to Assist with Medication

The school will not give any assistance with medication unless parental/carer permission has been given. Medicines should be stored strictly in accordance with product instructions, paying particular note to temperature, and in the original container in which it was dispensed with the patient's name clearly on each item.

Details of Pupil:

Surname Forename Address M/F Date of Birth Tutor Group Condition or illness

Medication

Name / Type of Medication (as described on the container) dosage For how long will your child take this medication? Date dispensed

Full directions for use

Dosage and method Timing Special precautions Side effects Self-administration Procedures to take in an emergency

Contact Details

Name Daytime telephone number Relationship to pupil Address

I understand that I must deliver the medicine personally to an agreed member of staff and accept that this is a service which the school is not obliged to undertake.

Signature (retype name) Date Relationship to pupil