Fillable CARE PLAN FOR HEALTH CONDITIONS, ALLERGIES OR MEDICAL (Fairfield Christian Academy)

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CARE PLAN FOR HEALTH CONDITIONS, ALLERGIES OR MEDICAL (Fairfield Christian Academy)

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CARE PLAN FOR HEALTH CONDITIONS, ALLERGIES OR MEDICAL PROCEDURES
FAIRFIELD CHRISTIAN ACADEMY
CHILDCARE & PRESCHOOL
Child's Name:
Date of Birth:
Please select one:
Health/Medical Condition Allergy Parental Preference
Please describe the health condition/allergy/preference below:
List any activities/foods/environmental conditions to avoid:
Symptoms to watch for and actions to be taken if the symptoms are observed:
Medical procedures to be followed and expected benefit of treatment:
Is any medication required? (If yes, the “Request for Administration of Medication"(attached below), must be
completed and signed by physician, in addition to this form.)
Yes No Type of medication:__________________________
Training Instructions (Trainer must be a parent/guardian or certified professional)
Signature of Trainer:
Date
Signature of child care staff members who have been informed about the child's condition so they can care for the child
according to this care plan or trained to perform the medical procedure.
There must always be a trained staff member present when the child is present.
Signature
Date
I have been
Informed
Trained
Signature
Date
I have been
Informed
Signature
Date
I have been
Informed
Signature
Date
I have been
Informed
Additional Services (educational/therapeutic) child is receiving:
Who provides these services?
Name: ____________________________ Phone Number__________________ May we contact? No Yes
Name: ____________________________ Phone Number__________________ May we contact? No Yes
I give my permission for the staff listed above to perform the procedures in my child’s Medical/Physical Care Plan
Parent's Signature
Date
Administrator's Signature
Date
Office of Early Learning and School Readiness
Preschool and School Age Child Care
Medication Form
Revised 7/11/2016
This form meets Ohio Administrative Code. Programs may use this form or build their own.
A Medication Form is a request for the administration of prescription and non-prescription medication.
A separate form must be completed for each medication.
Except in cases of emergency, families provide the first dose of any newly prescribed medication so that they may personally
observe the child's reaction.
Section I - Request for Administration of Medication
Name of Child
Child's Age
Medication Name
Staff Authorized to
Administer Medication
Physician Signature
Dosage
Dosage
Time/s
Date
All prescription medicine must be current within the last twelve months, kept in its original container and have a legible
label containing the child's name and written instructions for use from a licensed physician, nurse practitioner, or dentist.
All medicines must be kept in a place inaccessible to children. An inhaler or nonprescription medication may be available
to a school child with a special health condition with parental permission in accordance with the program's policy.
Section II - Authorized Staff Member Medication Log
Dosage Date/Time Dosage Amount Trained and Authorized Staff Member Signature
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CARE PLAN FOR HEALTH CONDITIONS, ALLERGIES OR MEDICAL (Fairfield Christian Academy)

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Completed 27 February 2021

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