Child’s Medical Needs Form – Madison Montessori Academy

INDIVIDUALIZED PLAN FOR A CHILD WITH MEDICAL NEEDS

This form must be completed for a child who has one or more acute* or chronic** medical conditions such that he or she requires additional supports, accommodation or assistance.

Student Information

Last Name

First Name

Date of Birth

Date Individualized Plan Completed

Photo of Child (recommended)

Medical Conditions

Diabetes Asthma Seizure Other

PREVENTION AND SUPPORTS

CHILD’S SPECIFIC SIGNS AND SYMPTOMS OF A NON-LIFE THREATENING ANAPHYLACTIC REACTION: (specific to the child, e.g. wheezing and itchy skin)

LIST OF MEDICAL DEVICES AND HOW TO USE THEM (if applicable):

LOCATION OF MEDICATION AND/OR MEDICAL DEVICE(S) (if applicable):

SUPPORTS AVAILABLE TO THE CHILD (if applicable):

SYMPTOMS AND EMERGENCY PROCEDURES

SIGNS AND SYMPTOMS OF AN ALLERGIC REACTION OR OTHER MEDICAL EMERGENCY:

PROCEDURE TO FOLLOW IF CHILD HAS AN ALLERGIC REACTION OR OTHER MEDICAL EMERGENCY:

PROCEDURES TO FOLLOW DURING AN EVACUATION:

PROCEDURES TO FOLLOW DURING FIELD TRIPS:

Additional Information Related to the Medical Condition (if applicable):

This plan has been created in consultation with the child’s parent / guardian.

Signature of Parent / Guardian

Date

Relationship to Child

The following individuals participated in the development of this individual plan (optional):

First and Last Name

Position / Role

Signature / Sign Off

First and Last Name

Position / Role

Signature / Sign Off

Frequency at which this individualized plan will be reviewed with the child’s parent/guardian:

SPECIAL INSTRUCTIONS

• *Acute: a condition that is severe and sudden in onset that, if left untreated, could lead to a chronic syndrome.

• **Chronic: a long-developing syndrome that can develop or worsen over an extended period of time.

• Each child with medical needs requires their own individualized plan. If significant changes and updates are required to this individualized plan, a new individualized plan must be completed.

• An additional individualized plan is not required for a child with an anaphylactic allergy, if the child does not otherwise have a medical need, as these children must already have an individualized plan under the anaphylactic policy.

• Children’s personal health information should be kept confidential.