Personalised Medical Action Plan for Students

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Please help us by including as much detail as necessary so that we have specific information about your child's needs in an emergency/medical situation.

Students Name *

Nature of illness/condition *

Family Doctor

Treatment

Medication required and description of treatment required (e.g my child reacts to bee stings by severe swelling to the area. Has been to the GP for treatment, but never hospitalised. Medication is 2 antihistamine tablets immediately. Get to a GP if the swelling doesn't go down.)

Medication required- Please include the name of the medication and the dose rate.

I understand that is it my responsibility to ensure any medication held by the school is within its dates and has not expired *

Yes

Required

Treatment Plan

I will update the school immediately if the medication, dose rate or treatment plan changes *

Yes

Emergency Contact Details

Emergency Contact 1 *

Emergency Contact 2 *

Emergency Contact 3 *

Medication Permission

NO medication will be given unless permission has been obtained. It must be clearly labelled with the child's name, clear dosage, the name of the medication, expiry date, and where it is to be stored (eg. fridge)

I give permission for the medication described above to be administered if and when necessary by the staff of Kaipaki School. *

Yes I give permission

Required

If my child requires short term medication (ie antibiotics) I will send an email or note to school which will give Kaipaki staff members permission to administer the medication.

Yes

Clear selection

In the event of an accident or sudden illness, I authorise Kaipaki School staff to obtain such medical assistance as may be necessary. *

Yes

Electronic signature *

Date *

YYYY

Submit

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