Individual Health Care Plan Individual Healthcare Plan Please enable JavaScript in your browser to complete this form. Please enable JavaScript in your browser to complete this form. Review (School responsible Name of School / Setting: Windlesham School & Nursery To get started, replace this text with your own. Child's Name: * Child's Year: *--- Select Choice --- Nursery Reception Year 1 Year 2 Year 3 Year 4 Year 5 Year 6 Date of Birth: * Address of Child: * Medical Diagnosis or condition: * Today's Date: * Review Date: To be completed by school Section Divider Family Contact Information Name: * Relationship to child * Contact Phone Number (Work): * Contact Phone Number (Home/Mobile): * Name of additional emergency contact: * Relationship to child: * Contact Phone Number (Work): * Contact Phone Number (Home/Mobile): * Section Divider Clinic / Hospital Contact: Name: * Phone Number: * GP Name: * GP Phone Number: * Who is responsible for providing support in school: (School to complete) Describe medical needs and give details of child's symptoms, triggers, signs, treatments, facilities, equipment or devices, environmental issues etc. * 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 pupils educational, social and emotional needs: Arrangements for school trips/visits will be agreed with parents Other information relevant: Describe what constitutes an emergency and the action to take if this occurs. What are the symptoms or signs to look out for? * The support team, with assistance from SLT, will be responsible for an emergency. Section Divider This section is to be completed by school staff - parents need not fill this in. Plan developed with: (School to complete) Staff training needed/undertaken - who, what, when Form copied to: Submit
