Prime Time Individual Plan Of Care Form

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

MonthDayYear
Date
Birthdate*

MonthDayYear
Date
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*
Name*
Address*
Phone Number*
Name
Address
Phone Number
Parent Signature*

Powered by Jotform SignClear
Date*

MonthDayYear
Date
Parent Signature*

Powered by Jotform SignClear
Date*

MonthDayYear
Date
Should be Empty: