Individual Health Care Plan

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Basic Details

This section will ask you to enter basic contact details for your child.
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Child's name* This field is required.
First Name
Last Name
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Child's year group* This field is required.
Year 7
Year 8
Year 9
Year 10
Year 11
Year 12
Year 13
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Date of birth* This field is required.
Date
Day
Month
Year
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Child's address* This field is required.
Street Address
Street Address Line 2
City
County
Postal Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Medical diagnosis or condition.* This field is required.You do not need to give details in this section - just the name of the condition.
7
All Health Care Plans must be supported with medical evidence. Please upload your medical evidence below.* This field is required.
Drag and drop files here
Select files to upload
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Family Contact Information

This section will ask for 2 sets of contact details of a parent/carer.
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Parent/carer 1 name* This field is required.
10
Relationship to child* This field is required.
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Work phone numberSkip if not applicable
12
Home/mobile phone number* This field is required.
13
Parent/carer 2 name
14
Relationship to child
15
Work phone numberSkip if not applicable
16
Home/mobile phone number* This field is required.
17
Clinic/Hospital Contact

This section will ask for you for details of the clinic and hospital your child attends.

If your child does not attend hospital, or a clinic, for their condition, you can skip the questions.
18
Hospital nameSkip if not applicable
19
Name of consultant/doctor/GPSkip for not applicable
20
Medical Needs

This final section asks you to describe the medical needs of your child.

Sections can be left blank if needed.
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Describe medical needs and give details of child’s symptoms, triggers, signs, treatments, facilities, equipment or devices, environmental issues etc* This field is required.
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Name of medication, dose, method of administration, when to be taken, side effects, contra-indications, administered by/self-administered with/without supervision* This field is required.
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Daily care requirements* This field is required.
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Specific support for the pupil’s educational, social and emotional needs* This field is required.
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Arrangements for school visits/trips etc* This field is required.
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Any other information
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Describe what constitutes an emergency, and the action to take if this occurs* This field is required.
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Parental Consent

This last section will ask you to sign and confirm the details.
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Parents/carers are responsible for contacting the school should there be any change to this plan. Please tick the box below to confirm all details you have entered are correct.* This field is required.
By ticking this box, you agree to all entered information being correct.
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