The Stoke Poges School
Child's name:
Class:
Date of birth:
Child's address:
Medical diagnosis or condition:
Today's date:
Review date of condition:
Family Contact Information
Parent/Carer name:
Relationship to child:
Phone number:
Alternative phone number:
Clinic/Hospital Contact
Name:
Phone number:
G.P.
Name:
Phone number:
Who is responsible for providing your child with support in school?
Medical Needs
Describe medical needs and give details of child's symptoms, triggers, signs, treatments, facilities, equipment or devices environmental issues etc.
Name of medication, dose, method of administration, when to be taken, side effects, contra-indications, administered by/self-administered with/without supervision.
How can we support your child's needs in school?
Does your child have any specific educational, social and emotional needs which they may require support with?
Please describe any specific requirements for school visits/trips etc.
Describe what constitutes an emergency and the action to take if this occurs.
Who is responsible in an emergency (state if different for off-site activities).
Any other information:
For office use only
Plan developed with:
Staff traning needed/undertaken - who, what, when?
Form copied to:
