Individual Health Care Plan

As per DFE guidance, we are required to gather all necessary information relating to students medical needs. This allows us to make all staff aware of any medical requirements or allergies and the best course of action, for your child, in case of an emergency.

If your child has any medical conditions, needs or requirements, please fill out this form, in as much detail as possible, by Friday 14th July 2023.

Where a section is marked with an *, it is a mandatroy section and must be filled in. You will not be able to continue to the next step or submit this form if these sections have not been filled in.

Student's Full Name* Student's Date of Birth* Home Address* Post Code*

Medical Conditions

Please provide as much detail as possible about any of your child's medical conditions or allergies Please provide as much detail as possible of any known symptoms or triggers relating to your child's conditions or allergies Please provide as much detail as possible relating to any medical requirements including treatments, facilities, equipment, devices or environmental factors Please provide as much detail as possible of any medication(s) your child has. Please include the name of the medication, required dosage, method of administration and at what time(s) this medication should be taken. Please provide as much detail as possible of any known side effects or contraindications

Does your child successfully self-manage their medication?Yes (please provide more details)No

If yes, please provide further details regarding your child's self-management of their medication

Does your child require any additional daily care support?Yes (please provide more details)No

If yes, please provide further details regarding your child's daily care support needs

Does your child require any specific support for their social, emotional or mental health and wellbeing?Yes (please provide more details)No

If yes, please provide further details of your child's social, emotional or mental health and wellbeing needs

Emergency Procedures

What constitutes an emergency for your child? Please provide as much detail as possible of any known signs, indicators, symptoms or triggers that may require emergency action by staff In the event of an emergency for your child, please provide as much detail as possible of any actions that need to be taken

SEND Needs (Including Irlens)

Does your child have any Special Educational Needs or Disabilities?Yes (please provide more details)No

Does your child have a statement or Educational Healthcare Plan?Yes (please provide more details)No

If you have answered yes to either of the above questions, please provide as much detail as possible relating to your child's SEND needs and/or statement or Educational Healthcare Plan Please provide as much detail as possible relating to any medical requirements including treatments, facilities, equipment, devices or environmental factors and triggers relating to your child's condition(s) Please provide as much detail as possible of any medication(s) your child has. Please include the name of the medication, required dosage, method of administration and at what time(s) this medication should be taken. Please provide as much detail as possible of any known side effects or contraindications

Does your child successfully self-manage their medication?Yes (please provide more details)No

If yes, please provide further details regarding your child's self-management of their medication

Does your child require any additional daily care support?Yes (please provide more details)No

If yes, please provide further details regarding your child's daily care support needs

Does your child require any specific support for their social, emotional or mental health and wellbeing?Yes (please provide more details)No

If yes, please provide further details of your child's social, emotional or mental health and wellbeing needs Please provide as much detail as possible of any additional procedures or requirements for school trips and/or extra-curricular activities Please provide as much detail as possible of any additional classroom or on-site procedures, adjustments or requirements relating to your child Please provide as much detail as possible of any additional classroom or off-site procedures, adjustments or requirements relating to your child Please provide as much detail as possible of any other additonal needs, requirements or information relating to your child that you feel we need to be aware of

Family Contact Details

In the event of an emergency, we need to know who are the best points of contact for your child. Please provide us with two emergency contact details.

First Family Contact

Full name of first emergency contact* First contact's relationship to student* First contact's primary contact number* First contact's secondary contact number

Secondary Family Contact

Full name of second emergency contact* Second contact's relationship to student* Second contact's primary contact number* Second contact's secondary contact number

Medical Consent

In order for medication (prescribed or otherwise) to be given at school, we must have written consent from parents and carers.

Please ensure the following section is filled out carefully and accurately.

Student's Full Name Name of Medication(s) Expiry date of medication(s)

Please select one of the followingMedication is to be administered as and when it is requiredOngoing prescribed course of medication

Please provide as much information related to the course duration of the medication(s) Please provide as much detail as possible relating to the dosage of the medication(s) Please provide the date of which medication(s) were prescribed Please provide as much detail as possible relating the times that the medication(s) are to be administered

Please tick where appropriateThe above listed medication has been purchased by me.The above listed medication has been prescribed by the family or hospital doctor.

Please tick where appropriateThis medication is a prescribed regular drug and we do not require calls for consent and it is to be administered as per the dosage and timings provided above.This medication is to be given as and when required and a call will be made for parental consent on each occasion.

By ticking this box your are digitally signing this Medical Consent FormI understand that the medication listed in this Medical Consent Form must be delivered to school by me or the following mentioned responsible adult.I accept that this is a service that the school is not obliged to undertake and agree to inform Fulston Manor School of any changes to doses or medication immediately.

Please enter the name of the additional responsible adult who is authorised to deliver medication into school on your behalf Parent/Carer Full Name Parent/Carer Email Address Parent/Carer Home Address

Parent/Carer and Student Consent

The following section must be completed by the student.

Student's Full Name*

Please tick to agree to the following statements*I agree with the information and content of this Individual Healthcare Plan.I give my consent for this plan to be shared as appropriate.

If you do not agree to either or both of the above statements, please provide details as to why

The following section must be completed by the parent/carer.

Parent/Carer Full Name*

Please tick to agree to the following statements*I agree with the information and content of this Individual Healthcare Plan.I give my consent for this plan to be shared as appropriate.

If you do not agree to either or both of the above statements, please provide details as to why