Prime Time Individual Plan Of Care Form

PRIME TIME EXTENDED LEARNING CENTER, LLC. INDIVIDUAL CARE PLAN
Child Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Grade
Parents names
Diagnosis: Attach diagnosis from doctor
What are the child’s strengths and abilities?
What health concerns does Prime Time need to know about?
What emergencies could arise?
How would you like us to handle the above emergency(ies)?
Do you have any special hints about techniques you know that work well with your child?
What medication(s) does the child take? (Prime Time needs a 3 day supply in case of an emergency, along with the original label that includes dosage and administration. These need to be prescriptions or have doctor’s written permission and instructions.)
What special accommodation does your child need?
Does your child receive any special accommodation in his/her classroom?
What special materials or equipment does the child need?
Is there any special training needed for staff?
If so, what training is necessary?
Is there anything else you can think of that would help us support your child and help him/her have a successful day?
List all emergency contacts Name
Name
Address
Phone Number
Format: (000) 000-0000.
Name
Address
Phone Number
Format: (000) 000-0000.
Name
Address
Phone Number
Format: (000) 000-0000.
Parent Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: