Individual Health Care Plan (IHCP)

Child's Name

First

Last

Class

Date of Birth

Child's Address

Address Line 1

City

State / Province / Region

Postal Code

Medical diagnosis or condition

Date form completed

Date

Time

Review date

Date

Time

Family Contact Information

Name

First

Last

Phone (work)

Phone (home)

Phone (mobile)

Relationship to child

Clinic/Hospital Contact

First

Last

Clinic/Hospital Phone

First

Last

GP Phone

Birth copied administered

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

Daily care requirements

Specific support for the pupil’s educational, social and emotional needs

Arrangements for school visits/trips etc

Other information

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)

Plan developed with

Staff training needed/undertaken – who, what, when

Form copied to

Family Contact Information

Our address

Contact us

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