APPENDIX B
PO Box 380, Westhampton, New York 11977
(631) 288-4658
MEDICAL MANAGEMENT PLAN
Dated:
This plan should be completed by the student's personal health provider/physician and parents/guardian and immediately updated by these persons with any new information in the future.
Effective Dates:
Student's Name:
Date of Birth:
Physical Condition (Identify and Explain):
Date of Diagnosis:
Grade:
Contact Information: Circle the primary contact person and phone number
Mother/Guardian:
Home Address:
Employer:
Employer's Address:
Telephone: Home Work: Cell:
Father/Guardian:
Home Address:
Employer:
Employer's Address:
Telephone: Home Work: Cell:
Who has custody of the child?
Student's Doctor/Health Care Provider:
Name
Address
Telephone:
Emergency Number:
Other Emergency Contacts:
Names:
Relationship:
Telephone: Home Work: Cell:
Notify parents/guardian or emergency contact in the following situations:
Recommended Monitoring of Child:
Specify any medical time requirements:
Can student perform own monitoring? ❑ Yes ❑ No
Exceptions:
Identify the type of any meter, monitor, nebulizer, applicator, needle, pump, or any other devices necessary for the student's Medical Management Plan (include model and instruction booklet):
What signs does the student demonstrate when student is symptomatic?
Foods to avoid, if any
Instructions for when food is provided to the students (e.g., as part of a party or food sampling event):
Exercise and Sports Limitations
List, identify and explain any restrictions to exercise, sports or any other activities:
Treatment Supplies to be kept at the School site and provided by parent/guardian are as follows (please provide specific instructions regarding the storage and treatment of all supplies):
For Students with medical concerns, please complete the supplemental form.
This Medical Management Plan has been approved by:
__________________________________ __________________________Student's Physician/Health Care Provider Date
I give permission to the school to perform and carry out the care tasks as outlined in the Medical Management Plan. I also consent to the release of the information contained in this Medical Management Plan to all staff members and other adults who have custodial care of my child such as those persons on the emergency list and who may need to know this information to maintain my child's health and safety. A written revocation or amendment to this document must be delivered to the school nurse byt the student's Parent/Guardian in order to effectuate a revocation of the same. The school reserves the right to request additional documentation after review of the within document.
Acknowledged and received by:
__________________________________ __________________________
Student's Parent/Guardian Date
__________________________________ __________________________
Student's Parent/Guardian Date