JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Personalised Medical Action Plan for Students
Please help us by including as much detail as necessary so that we have specific information about your child's needs in an emergency/medical situation.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Students Name
*
Your answer
Nature of illness/condition
*
Your answer
Family Doctor
Your answer
Treatment
Medication required and description of treatment required (e.g my child reacts to bee stings by severe swelling to the area. Has been to the GP for treatment, but never hospitalised. Medication is 2 antihistamine tablets immediately. Get to a GP if the swelling doesn't go down.)
Medication required - Please include the name of the medication and the dose rate.
Your answer
I understand that is it my responsibility to ensure any medication held by the school is within its dates and has not expired
*
Yes
Required
Treatment Plan
Your answer
I will update the school immediately if the medication, dose rate or treatment plan changes
*
Yes
Emergency Contact Details
Emergency Contact 1
*
Your answer
Emergency Contact 2
*
Your answer
Emergency Contact 3
*
Your answer
Medication Permission
NO medication will be given unless permission has been obtained. It must be clearly labelled with the child's name, clear dosage, the name of the medication, expiry date, and where it is to be stored (eg. fridge)
I give permission for the medication described above to be administered if and when necessary by the staff of Kaipaki School.
*
Yes
Required
If my child requires short term medication (ie antibiotics) I will send an email or note to school which will give Kaipaki staff members permission to administer the medication.
Yes
Clear selection
In the event of an accident or sudden illness, I authorise Kaipaki School staff to obtain such medical assistance as may be necessary.
*
Yes
No
Electronic signature
*
Your answer
Date
*
MM
/
DD
/
YYYY
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Kaipaki School.
Does this form look suspicious?
Report
Forms
Help and feedback
Help Forms improve
Report