Lollipop Youth Theatre    Care Plan Form 2025
Please fill in all questions with full details to help us care for your child. We need to know about any medical conditions or allergies your child may have so we can give them the best care. 
Name of Young Person *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Address *
Your answer
Postcode *
Your answer
Emergency Contact Name *
Your answer
Emergency Contact Number *
Your answer
Doctors Surgery Name *
Your answer
Doctors Surgery Address *
Your answer
Doctors Surgery Phone Number *
Your answer
Does your child have any allergies or intolerances? (please go into detail) *
Your answer
Does your child have any medical conditions (please note down everything and go into detail) *
Your answer
Are there any particular triggers or symptoms that could exacerbate your child’s medical condition or allergies?
 *
What are their triggers or symptoms? *
Your answer
Does your child have any phobia’s that can cause distress? (scared of the dark, scared of spiders etc) *
Your answer
If your child is triggered by their phobia during their time with us what can we do to care for them? *
Your answer
Does your child take any medication for their condition or allergies? *
Will your child need medication when in our care? *
Do you agree to bring the medication in a labelled box with the child’s name and details on it. (If it isn’t we can not administer it) *
Do you give permission for our nominated first aider to administer the medication or oversee your child taking it if they are old enough? (Parents will have to fill in the medication book) *
Could you provide a list of measures we can take to ensure that your child receives the best possible care while with us? Additionally, what steps can we implement to assist them in the event of an incident during their time here? Please elaborate with detailed information.
 *
Your answer
Get link
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms