St Marys South Public School

Student Health Condition Support

Dear Parents/Carers,

You have indicated your child has a health condition which may require support at school or when involved in school activities, for example, a school excursion. While the main role of the school is to provide education, we want to work with you to keep your child healthy and safe at school. Please complete the attached form Request for support at school of a student’s health condition, based on information provided by your medical practitioner and return it to me. (You may wish to discuss the information required with the medical practitioner.) The form includes sections where you can request the administration of prescribed medication and/or other assistance. When I receive your request for support, I will need to discuss it with relevant staff, and I will then contact you again. Please advise me at any time if there are changes in the information about your child’s health care needs or if I can assist you.

Yours sincerely

Mrs Treton

Principal

This request form includes 4 sections:

1. Student details

2. Request for administering prescribed medication

3. Request for other support

4. Parent and emergency contact details

Please remember to sign and date this form.

1. Student details

First name:

Last name:

Date of Birth:

Enrolled at this school:

Yes

Class if currently enrolled:

Current school if not enrolled:

Health/medical condition:

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

Yes

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.

Allergy/medical condition

Doctor’s name

Address

Telephone

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.

2. Request for administering prescribed medication

Note: if your child is to take more than one prescribed medication, please attach a separate request for each medication.

Name of prescribed medication:

Prescribed for (name of medical condition):

Prescribed dosage and time to be administered:

What are you requesting the school to do?

Expiry date of the medication:

Note: if you can’t provide this information now, we will need to know the expiry date when the medication is given to the school.

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?

Yes

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?

Yes

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: All medication must be provided to the school in its original pharmacy packaging (Box & Blister pack with label showing name & dosage. We are unable to accept medication that comes in zip lock bags.)

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?

Yes

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.

Note: Your child’s medication should be clearly labelled with their name.

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 and emergency contact details

Name:

Relationship to child:

Address:

Home phone:

Work phone:

Mobile phone:

Email:

Parent or Carer signature: *

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Date: *

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 Principal.

Please upload any supporting documents below

An emergency care/response plan for Anaphylaxis (ASCIA Action Plan for Anaphylaxis)

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An emergency care/response plan for Allergies (ASCIA Action Plan for Allergies)

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An emergency care/response plan for Eczema (ASCIA Action Plan for Eczema)

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An emergency care/response plan for Asthma (Asthma Plan)

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Other documents – please specify. Note: For anaphylaxis this should include strategies to minimise the risk of exposure to known allergens and details of communication and staff training strategies. See the Anaphylaxis Procedures for Schools for further information.

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Request for Medication Support at School

St Marys South Public School