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
Students Name *
Nature of illness/condition *
Family Doctor
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.
I understand that is it my responsibility to ensure any medication held by the school is within its dates and has not expired *
Treatment Plan
I will update the school immediately if the medication, dose rate or treatment plan changes *
Emergency Contact Details
Emergency Contact 1 *
Emergency Contact 2 *
Emergency Contact 3 *
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. *
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.
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. *
Electronic signature *
Date *
Clear form
Never submit passwords through Google Forms.
This form was created inside of Kaipaki School. Report Abuse