Individual Healthcare Plan (IHP) for short term health condition 

Please complete all fields marked (*)

Your first name *

Your last name *

Your email *

Terms and Conditions: The school will only administer prescribed medication that is required 4 x a day or 3 x a day if the child is attending the full session of extended day club. 3 x a day medication can usually be managed at home around the school day. Please tick that you have read and understood

Child's name

Child's Date of Birth

Class

Medical condition

Name and Type of Medicine

Expiry date of Medicine

Date to be dispensed from

Date we need to give last dosage

Dosage

Time to administer medicine

Please add if there are any notes, e.g. dispensing information (before food, with water etc.)

I accept the school will only accept prescribed medication in the original dispensed container with pharmacist label,, that this is a service that the school is not obliged to undertake. I understand that I must notify the school of any changes in writing. The above information is to the best of my knowledge accurate at the time of writing and I give the school staff consent to administer the above medication in accordance with the school policy. After the dates above have ended you will need to either collect medication or submit a new form. Please tick that you understand and agree

Please provide a signature. *

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