West Wallsend High School

While the main role of the school is to provide education, we want to work with you to keep your young person healthy and safe at school. If your young person has a health condition which requires support at school or during school activities e.g. a school excursion you must advise the school.

Please complete the attached form based on information provided by your medical practitioner and return it to the Head Teacher Wellbeing. You may wish to discuss the information required with your medical practitioner.

The form includes sections for you to request the administration of prescribed medication and/or other assistance.

Once your form has been returned it will be given to the Head Teacher Wellbeing to review. They will consult with relevant staff members and a member of the wellbeing team will contact you for further details (if required) or to confirm if a health care plan needs to be developed.

Please advise the Head Teacher Wellbeing whenever there are changes to the information about your young person’s health care needs.

Student Health Condition: Request for Support

This request form includes 4 sections:

Student details
Request for administering prescribed medication
Request for other support
Parent and emergency contact details

1. Student details

Student's full name *

Date of birth *

Currently enrolled

Yes

Health/medical condition *

Could your child experience an emergency reaction in relation to this condition? *

Doctor's name/medical centre

Doctor's address

Doctor's phone number

Please provide the name, address and phone number of any other doctor or medical specialist who may currently be treating your child.

If your child has a documented plan to support any health or medical needs from a previous school or organisation (e.g. preschool, occasional care, etc) please provide it to the school as an attachment to this form.

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2. Request for administering prescribed medication to the student

Note: if your child is to take more than one prescribed medication, please complete the additional request for administering prescribed medication form for each medication.

Name of prescribed medication

Prescribed for (name of medical condition)

Prescribed dosage

What are you requesting the school to do?

Expiry date of the medication

Special storage requirements if any e.g. in refrigerator:

Special instructions for administering the prescribed medication/s e.g. must be taken with food or with a glass of water:

Through information you have obtained from your doctor or got yourself, are you aware of any likely side effects from the prescribed medication? *

If Yes, please provide more information:

If your child administers his or her own medication at home, do you request that he or she self administers this medication at school?

Note: the Principal needs to approve a decision for a student to self administer.

If yes, please describe what support your child needs to administer the medication in a non emergency situation at school. You may like to include information about how you support your child at home to administer their medication.

Note: Medication should be provided to the school in its original pharmacy/labelled packaging, including the name of the student and the dose.

Secure delivery of prescribed medication is important for the safety of your child as well as for the safety of other students in the school.

Please name the person who will carry the medication to school

Note: if you are unable to deliver the medication to school, it is advisable that you nominate a responsible person, who is not a school staff member, to transport the medication to the school.

For some medications and some students it can be appropriate for them to carry their own medication to and at school. For example, asthma reliever medication and pancreatic enzymes for cystic fibrosis. If your child is to carry their own medication we want to be able to support this and request some information so that we are well informed.

Note: The school may still need you to provide an additional supply of the medication for storage in central location/s within the school and for use if your child needs the school’s help.

Would you like the principal to consider a request for your child to carry their medication?

Note: The Principal needs to approve a decision for a student to carry their own medication at school.

If yes, please describe where and how your child will carry this medication, for example, my child will carry it on their person in a medical pouch or bum bag.

3. Request for other support

Please provide details of any other health care support needs of your child while they are at school and involved in school activities.

4. Parent contact details

Parent/Carer name *

Relationship to child

Phone

Address

Signature *

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Privacy Notice:

The information requested on the form is essential for assisting the school to plan for the support of your child’s health needs. It will be used by the NSW Department of Education and Communities for the development of arrangements with you to support your child’s health needs. Provision of this information is voluntary. If you do not provide all or any of this information, the school’s capacity to support your child’s health needs could be impaired. This information will be stored securely. You may correct any personal information provided at any time by contacting the school and/or the Head Teacher Wellbeing.

	Condition details	Doctor's name	Doctor's address	Doctor's phone number
Allergy/medical condition
Allergy/medical condition
Allergy/medical condition
Allergy/medical condition