Ewell Grove Health Care Plan Online Form

Please complete this online form if your child requires a Health Care Plan. The office will then be in touch to discuss this with you.

If submitted online a copy of this form will be send to your supplied email address for your records.

Child's first name* Child's surname* Child's Class:* Home address:* Child's date of birth:* Parent's Name:* Parent's Home/Mobile Telephone no:* Parent's Work no:* Medical Diagnosis or Condition:* Name of GP who prescribed medication:* GP Telephone no:* Review Date* Describe medical needs and give details of your child’s symptoms:* Daily care requirements (e.g. before sport/at lunchtime):* Specific support for the pupil’s educational, social and emotional needs:* Arrangements for school visits / trips etc:* Describe what constitutes an emergency for your child and what action to take should this occur:* Please confirm in order, who should be contacted in case of an emergency. Please also confirm their contact numbers:*

Please tick the appropriate boxes:

I confirm that the stated medicine has been prescribed by a GP for my child.*YesNo

I agree to members of staff administering medicines/providing treatment to my child as directed below.YesNo

I confirm that the stated medicine has been prescribed by a GP for my child.YesNo

My child will be responsible for the self-administration of medicines as directed below.YesNo

	Name of Medicine	Dose	Frequency	Expiry Date	Special instructions:
Medicine 1
Medicine 2
Medicine 3

Special Instructions- i.e before or after lunch Other prescribed medicines child takes at home: Allergies or any known possible reactions:

The above information is, to the best of my knowledge, accurate at the time of writing and I give consent to Ewell Grove staff administering medicine in accordance with the school’s policy.

I will inform Ewell Grove Primary & Nursery School immediately, in writing, if there is any change in dosage or frequency of the medication or if the medicine is stopped.

Name and date in lieu of a signature* Parent's email address:*