Standard Care Plan
For students with Chronic Medical Conditions and for whom medication may be required during the school day. Each plan must be informed by medical advice.
1. Medical Condition and Administration of Medicines
Student's Name*
First Name Last Name
Student's Address*
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Child's Date of Birth*
Day Month Year
Date
Parent/guardian's email*
example@example.com
Emergency contacts*
Name Phone Number
Parent/guardian 1
Parent/guardian 2
Child's doctor
What is your child's medical condition*
Anaphylaxis Diabetes Asthma Epilepsy
Prescription details*
Storage details*
Dosage details*
Is the child to be responsible for taking the prescription him/herself?*
Yes Normally, yes, but may need assistance in an emergency No
What Action is required?*
I/We request that the Board of Management authorise the taking of Prescription Medicine during the school day as it is absolutely necessary for the continued well being of my/our child. I/We understand that the school has no facilities for the safe storage of prescription medicines and that the prescribed amounts be brought in daily. I/We understand that we must inform the school/Teacher of any changes of medicine/dose in writing and that we must inform the Teacher each year of the prescription/medical condition.
I/We understand that no school personnel have any medical training and we indemnify the Board from any liability that may arise from the administration of the medication.
Parent/guardian 1*
Clear
Parent/guardian 2 (if necessary)
Clear
Date*
Day Month Year
Date

	Symptom resulting in use	Dosage	In-date medication provide to school (parents' responsibility to replace)
Antihistamine
Inhaler

	Name	Phone Number
Parent/guardian 1
Parent/guardian 2
Child's doctor

Standard Care Plan

1. Medical Condition and Administration of Medicines