(Insert school crest and contact details)
Dear
You have indicated <insert context eg. on your child ’s enr olment fo rm, on an
excursion consent form or to your child’s teacher> that your child has a
health condit ion which may r equire support at school or when involved in
school act ivities, f o r example, a school excursion W hile the main role of the
school is to provide educat ion, we want to work with you to keep your child
healthy and saf e at school.
Please complete the attached f orm Request for support at school of a
student ’s health condit io n, on the basis of inf ormation provided by your
medical practit ioner and retur n it to me . (You may wish to discuss t he
inf ormation required with the medical pract itioner.) The f orm includes
sections where you can request the administration of prescribed me dicat ion
and/or other assistance.
W hen I receive your request f or support I will need to discuss it wit h relevant
staff and I will then contact you again .
Please advise me at any t ime if there are changes in the inf ormation about
your child’s health care n eeds or if I can assist you.
Yours sincerely
Name of Principal………………………………………………..
Signature of Principal……………………………………………
Date…………………….
(Insert school crest and contact details)
Request for support at school of a student’s health condition
This request f orm includes 4 sections:
1.
2.
3.
4.
Student details (page 1)
Request f or administering prescr ibed medication (page 2)
Request f or other support (page 4)
Parent and emergency contact det ails (page 5)
Please remember to sign and date the f orm on page 5 bef ore returning it to
the school.
1. Student details
First name: ................................................ Last name: ...........................
Date of Birth: ..........................................................................................
Enrolled at this school
Yes
No
Class if currently enrolled: ...........
Current school if not enrolled: ..................................................................
Health/medical condition :
..............................................................................................................
..............................................................................................................
Could your child experience an emergency reaction in relation to this
condition? (please tick)
Yes
No
Doctor ’s name/medical cen tre: ..................................................................
Doctor ’s address: ....................................................................................
Doctor ’s phone number: ...........................................................................
Please provide the name, addr ess and phone number of any other doctor or
medical specialist who may current ly be treating your child .
A l ler g y/m e d ic a l
c on d it i o n
Doc tor ’s n am e
A ddr es s
T ele p h on e
If your child has a documented plan to support any health or medical needs
f rom a previous school or organisat ion (eg preschool, occasional care, etc)
please provide it to t he school as an attachment to this f orm.
Parent request for support at school of a student’s health condition
Page 1 of 5
(Insert school crest and contact details)
2. Request for administering prescribed m edication to the
student
No te : i f y o ur c h i l d is t o t ak e mor e t h an on e pres c ri b ed m ed ic at i on , p le as e a tt ac h a
s ep ar at e re q ues t fo r e ac h me d ic at i on .
Name of prescribed medication: ................................................................
Prescr ibed f or (name of medical condition): ................................................
Prescr ibed dosage: ..................................................................................
W hat are you requesting the school to do ? .................................................
..............................................................................................................
..............................................................................................................
Expir y date of the medication: ..................................................................
No te : if y o u c a n ’t pr ov i de th is i nf or ma t io n no w w e w i l l n e ed t o k n o w t he ex p iry d at e
wh e n th e m e dic a ti o n i s g iv en t o t he s c ho o l.
Special storage requirements if any eg in ref rigerator: .................................
..............................................................................................................
Special instruct ions f or administer ing the prescribed medicat ion/s eg must
be taken wit h f ood or with a glass of wat er:
..............................................................................................................
Through inf ormation you have obtained f rom your doctor or got yourself ,
are you aware of any likely side ef f ects f rom the prescribed m edication?
Yes
No
If Yes, Please pr ovide more inf ormation:
..............................................................................................................
If your child administ ers his or her own medication at home, do you request
that he or she self administers this medication at school?
Yes
No
No te : t he Pr inc i pa l n e eds t o a p pr ov e a d ec is i on f or a s t ud e nt t o s e l f ad m i nis t er .
If yes, please describe what support your child needs to administer the
medication in a non emergency situat ion at school. You may like to include
inf ormation about how you support your child at home to administer their
medication.
..............................................................................................................
..............................................................................................................
Parent request for support at school of a student’s health condition
Page 2 of 5
(Insert school crest and contact details)
Secure deliver y of prescribed medicat ion is important f or the saf ety of your
child as well as f or the saf ety of other students in the school.
Please n ame the per son who will carry the medication to school:
..............................................................................................................
No te : if y ou ar e u n ab l e t o d e l iv er th e me d ic at i on to s c h oo l , i t is a dv is a b le th a t y o u
no m i na t e a r es p ons i b l e p er s on , w ho is n ot a s c ho o l s ta ff m em b er, to tr a ns por t t he
me d ic at i on t o t he s c ho o l.
For some medications and some students it can be appropriate f or them to
carry t heir own medication to and at school. For example, asthma reliever
medication and pancreatic enzymes f or cyst ic f ibrosis. If your child is to
carry their own medication we want to be able t o support this and request
some inf ormation so that we ar e well inf ormed.
No te : T he s c ho o l m a y s ti l l n e ed y ou to p rov id e t h e s c h oo l w i t h a n a d di t io n a l
s up p ly of t he me d ic a t i on f or s tor a ge in c e ntr a l loc a ti o n/s w it h i n t h e s c h oo l a nd f or
us e if y o ur c h i l d n ee ds t he s c ho o ls h el p .
W ould you like the principal to co nsider a request f or your child to carr y
their medicat ion ?
Yes
No
No te : Th e Pr i nc i pa l n ee ds t o a ppr ov e a d e c is io n f or a s t ud e nt t o c arry t h e ir ow n
me d ic at i on at s c h o ol .
If yes, please descr ibe where and how your child will carr y this medicat ion,
f or example, m y child will carr y it on their person in a medical p ouch or bum
bag.
..............................................................................................................
..............................................................................................................
..............................................................................................................
No te : Y o ur c h i ld ’s m e d ic at i on s h o u ld b e c le ar ly l a be l l ed w i th t h e ir n am e ..
Parent request for support at school of a student’s health condition
Page 3 of 5
(Insert school crest and contact details)
3. Request for other support
Please provide det ails of any other healt h care support needs of your child
while they are at school and involved in school act ivit ies.
..............................................................................................................
..............................................................................................................
..............................................................................................................
..............................................................................................................
..............................................................................................................
..............................................................................................................
..............................................................................................................
..............................................................................................................
..............................................................................................................
Parent request for support at school of a student’s health condition
Page 4 of 5
(Insert school crest and contact details)
4. Parent contact details
Name: .....................................................................................................
Relationship to child: ................................................................................
Address: .................................................................................................
Home phone: ................................... W ork phone: .....................................
Mobile phone: ..........................................................................................
Email: ....................................................................................................
Parent or car er signature: ......................................... 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.
Parent request for support at school of a student’s health condition
Page 5 of 5