Individual Health Care Plan

Please fill out this form in its entirety. All fields MUST be completed in order to submit the form. Please mark NA if a certain field does not apply to your child. Thank you.

Plan was created by

Plan is maintained by

Parent

Doctor or Licensed Practioner

Program's Health Care Consultant

Other

Name of Child

Photo of Child

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Date

Any change to the child's Health Care Plan?

Name of chronic health care condition

Description of chronic health care condition

Symtoms

Medical treatment necessary while at the program

Potential side effects of treatment

Death can result if treatment is not administered

Yes

Potential consequences if treatment is not administered

Name of educators that received the training addressing the medical condition

Person who trained the educator (child's Health Care Practitioner, child's parent, Health Care Consultant)

Name of Licensed Health Care Practioner

Best of Boston 2017 - (857) 259-5211

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Individual Health Care Plan

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