Health care plan for The Ark Preschool and Daycare

Name of child 

 

Child's date of birth

 

Address of child

 

 

 

 

 

Medical condition or illness

 

Date 

 

Review date

 

Family contact details

Name

 

Relationship to child

 

Daytime phone no.

 

Mobile

 

Name

 

Relationship to child

 

Daytime phone no.

 

Mobile

 

Medical details

Name of Hospital

 

Name of Clinic/Deptartment

 

Name of Consultant

 

Daytime phone no.

 

Name of GP

 

Daytime phone no.

 

Describe medical needs and child’s symptoms

 

 

 

 

 

 

 

Daily care requirements

 

 

 

Describe what constitutes an emergency and action to be taken

 

 

 

Follow up care

 

 

 

 

If required, has a risk assessment been completed? (e.g. child with allergy, risk assess likelihood of exposure and control measures etc.) Yes / No

Name of person responsible in an emergency

 

Form copied to

 

Parent’s name

 

Signature

 

Date

 

Key person’s name

 

Signature

 

Date

 

Manager’s name

 

Signature

 

Date

 

Review date

 

A copy of this form must be given to the parent. The setting will keep the original in the child’s personal file.