Child: ______________________________________Birthdate: _______________________
Parent(s) or Guardian(s): ______________________________________________________
Phone #: _________________________ Alternate Phone #:__________________________
Primary Health Care Provider: __________________________________________________
Primary Health Care Provider Phone #: ___________________________________________
DIAGNOSIS:
1. _________________________________________________________________________
2. _________________________________________________________________________
3. _________________________________________________________________________
Routine Care
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Medication
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When
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How Much
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How
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Possible Side Effects
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Describe accommodations the child needs in daily activities
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Diet or Feeding
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Naptime/Sleeping
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Toileting
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Outdoor Activities/Field Trips
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Transportation
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Other
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Emergency Care
Call parents for: ______________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
While waiting for parent/guardian or medical help to arrive: ____________________________
_____________________________________________________________________________
_____________________________________________________________________________
Give as Needed or Emergency Medication for: _______________________________________
_____________________________________________________________________________
_____________________________________________________________________________
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Medication
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When
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How Much
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How
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Possible Side Effects
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Get medical attention for: ________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
CALL 911 (Emergency Medical Services) FOR:
_________________________________________
______________________________________________________________________________
______________________________________________________________________________
Date plan completed: _______________ Plan will be updated on or before: ________________
Parent(s) or Guardian(s):
_________________________________
__ ______________________________________
Staff Name(s) & Title(s):
_________________________________
__ ______________________________________
_________________________________
__ ______________________________________
Health Care Provider Name(s) & Title(s):
_________________________________
__ ______________________________________
_________________________________
__ ______________________________________