TCA Individual Health Care Plan (IHCP)
Parent Name
*
First Name
Last Name
Student Name
*
First Name
Last Name
Student Age
*
`Student Grade
*
Please Select
Pre-K
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Was TCA provided the students emergency medication? (I.E. EpiPen, Inhaler, ETC)
*
Yes
No
Emergency Medical Care Plan (Physician Provided)
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Medical Condition(s)
Emergency Health Care Plan
Parent/Guardian Signature
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