Shared Plan of Care

Written Care Plan Complete the portions that are helpful for your child and your child care provider. This plan can be used for any child or any time a place is needed to share information about caring for a child. It is not necessary to complete all sections of the form, please use the sections that are applicable and helpful for your child and child care provider. Completed By

Guardians Names

Child Name

Childs First NameLast Name

Middle

Sex

Birthdate

Date

Age

My family wants you to know

My preferences include

Health Information please include information about previous serious illness or injury or any ongoing health issues

Allergies

Medication

Modifications or accommodations may be needed for

RECOMMENDATIONS Diet or Feeding

Activity

NappingSleeping

Toileting

Outdoor Play

Field Trips

Transportation

Adaptive or accessibility tools and equipment 1.

1

2

3

Situations and Experiences Things that work for my child

Things that may not work for my child

Things that definitely do not work for my child

When my child is feeling seen heard and valued they

When my child feels out of place or upset they may show this by

When my child is upset you can help them by

Helpful strategies used at home

EMERGENCY RESPONSE PLANS CALL PARENTS GUARDIANS if the following

CALL 911 EMERGENCY MEDICAL SERVICES if the following

TAKE THESE MEASURES while waiting for family members or medical help to arrive

Special factors to consider in a facility emergency like a fire

Team Members / Support (Name, Program, & contact information, if applicable) Guardian(s)

Guardians

Primary Child Care Caregivers

Public / private School Teacher

Health Care Provider MD NP

If desired please add other members of your childs support team below which may include but is not limited to Occupational therapist OT Physical Therapist PT SpeechLanguage Therapist Transportation Social Worker a Specialist or other family members

INDIVIDUALIZED SERVICES Parent permission is granted for these services to happen at the child care facility include type of service how often the name of the agency providing the service and end date if applicable

Action Plan (if relevant, specify any follow-up needed here) Action

Action

Who

When

NOTES

Date

Parent Signature