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THE STOKE POGES SCHOOL

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Healthcare Plan

Healthcare Plan

The Stoke Poges School

Child's Name* Child's Class* Date of Birth* Child's address* Medical diagnosis or condition* Today's date* Review date

Family Contact Information

Main contact name* Main contact telephone number* Alternative contact telephone number Secondary contact name Secondary contact telephone number Alternative contact telephone number

Clinic/Hospital Contact

Name Telephone number

G.P

Name* Phone number Describe medical needs and give details of child's symptoms* Daily care requirements (e.g. in the classroom, before sport/at lunchtime)* Describe what constitutes an emergency for the child, and the action to take if this occurs Follow up care Who is responsible in an emergency (state if different for off-site activities)

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Healthcare Plan
Parental agreement to administer medicine

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