Staff Health Care Plan

Staff Health Care Plan

This online form is to be used to document all of your health care conditions that may require treatment, including emergencies, whilst at The Little Lane Nursery.
Your Full Name*

First NameLast Name
Your Date of Birth*

DayMonthYear
Date
Medical Condition

Please provide details of the medical condition you have:
Condition being treated:*
Please describe what an emergency situation looks like or an event when treatment would be required - including symptoms to look out for:*
What care is involved day to day? Anything additional you require from us? Please provide details:*
Treatment plan - please describe the treatment plan:*
Medical Professional

Please provide details of the medical professional your Child is under the care:
Medical Professionals Name*

SalutationFirst NameLast Name
Profession (i.e. rheumatologist, paediatrician etc)*
Contact Phone Number*

Area CodePhone Number
Medication

Please provide details of any medication your Child has been prescribed in relation to this condition:
Name of current medication(s) and dose(s) to be administered:*
Any further information about medication(s):*
Copy of current medication prescription from Medical Professional (for example a photo of current medication prescription). Without confirmation of a current prescription, we will be unable to administer medication.

Cancelof
Emergency Contact Details

In the event of an emergency, please provide the primary and secondary emergency contact details below
Primary Contact - Name*

SalutationFirst NameLast Name
Primary Contact - Relation to you*
Primary Contact - Phone Number*

Area CodePhone Number
Secondary Contact - Name*

SalutationFirst NameLast Name
Secondary Contact - Relation to you*
Secondary Contact - Phone number*

Area CodePhone Number
Any additional information - please use this section to provide any details not covered in the previous sections.
Signature
Parent 1 Signature*

Clear
Date*

DayMonthYear
Date
Nursery Signature

Signed on behalf of The Little Lane Nursery
Emma Green

Nursery Manager
Date

DayMonthYear
Date
All health care plans will be reviewed at least every 6 months, unless anything changes sooner or within the first 6 months following a diagnosis.
Should be Empty:

Medical Condition

Medical Professional

Medication

Emergency Contact Details

Signature

Nursery Signature

Emma Green

All health care plans will be reviewed at least every 6 months, unless anything changes sooner or within the first 6 months following a diagnosis.