Personalised Medical Action Plan for Students

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

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.

Students Name *

Class Teacher / Room / Year *

Family Doctor *

Prescribing Doctor *

Medical condition requiring medication: *

Name of medication: *

Dosage: *

Does the medicine need to be kept in the fridge?

Yes

Clear selection

Preferred time(s) for medicine to be given: *

Duration of medication: (e.g. end date or ongoing or take until finished) *

Additional info: (e.g. side effects to look out for or N/A) *

Please read the following statements and sign below to indicate your agreement. *

I accept responsibility for the decision to give this medication to my child and acknowledge that the school is in no way responsible for that decision, now or in the future.

I assure the school that this is not the first time my child has been given this medicine (i.e. the first dose was given at home).

I accept that the school may not have trained medical personnel to administer medications.

I accept that the school cannot guarantee that the medication will be given at a precise time or by the same person.

I will notify the school about any changes in dosage, time, or procedures by filling out a new Medicine Authority Form.

I will deliver the medication personally to school in its original packaging.

I will ensure that the medicine is not past its expiry date.

I accept that the school will dispose of any uncollected medicine at the end of the year.

I understand that it is my responsibility to supply medicine needed when of site (e.g. trips, camps).

Required

Electronic signature *

Date *

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