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IHCP Form

Name *

First

Last

Date of Birth *

Year Group *

Medical Diagnosis/Condition (if N/A please state) *

Allergies *

Review Date *

Name *

First

Last

Relationship to child *

Phone *

Name *

First

Last

Relationship to child *

Phone *

GP Name *

Contact Number *

Class Teacher/HOY *

Medication and Dose *

Route *

When does it need to be taken? *

Please state if administration needs to be with or without supervision *

Side effects (does the treatment affect behaviour or concentration)? *

Special precautions/other instructions *

NB: ALL PRESCRIBED MEDICATION MUST BE IN THE ORIGINAL CONTAINER, AS DISPENSED BY THE PHARMACY WITH CLEAR INSTRUCTIONS ON HOW MUCH TO GIVE.

Describe medical needs and give details of the child’s symptoms, triggers, signs, treatments, facilities, equipment or devices, environmental issues, etc. *

Daily care requirements (including physical activity, cooking in school, etc.) Specific support for the pupil’s educational, social, and emotional needs (Pupils with medical conditions may have to attend clinic appointments to review their condition. These appointments may require a full day’s absence and should not count towards a child’s attendance record)

Arrangements for school trips and activities away from school *

Emergency Procedure

Follow up care

Emergency medication held by KAS

In the event of the above named child displaying symptoms of anaphylaxis/asthma attack/epilepsy, and if their medication is not available or is unusable: *

I consent for my child to receive emergency medication held by the school for such emergencies.
I do not consent for my child to receive emergency medication held by the school for such emergencies.

To the best of my knowledge, the above information is accurate at the time of writing, and I give consent to school staff administering the medication. I will inform the school immediately, in writing, if there is any change in dosage or frequency or if the medication is stopped.

Student Signature *

Clear Signature

Print Name *

Parent Signature *

Clear Signature

Print Name *

Date *