Horizon Youth Winter Camp 2024

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Horizon Youth Winter Camp 2024 - Health Care Plan

The information provided in the above Health Care Plan is essential for assisting Horizon Youth Leaders to support your child’s health needs. Provision of this information is voluntary. If you do not provide all or any of this information your child’s health needs could be impaired. This information will be stored securely and the information will be provided to relevant Horizon Youth Leaders who will have contact with your child.

Email *

Child's Name *

Date of Birth *

YYYY

Parent Contact Information

Parent Name *

Relationship to Child *

Address

Home Phone

Work Phone

Mobile Number *

Other contact (if unavailable)

Medical Practitioner/ Doctor Contact

Name of Doctor

Address

Contact Number

Health Care Information

Health Condition(s) *

Emergency Care Issues

Is there an emergency care plan attached?

Yes

Clear selection

Medication Details

Name of prescribed Medication *

Prescribed Dosage & Frequency *

Special storage requirements *

Special instructions for administering the prescribed medication (eg must be taken with food/water) *

Are there any side effects & what are they? *

Who would you like the medication stored with? *

Allow child to keep medication on their persons and self-administer

Keep medication with responsible designated adult that will provide medications as necessary

N/A

Medication Details 2

Name of prescribed Medication

Prescribed Dosage & Frequency

Special storage requirements

Special instructions for administering the prescribed medication (eg must be taken with food/water)

Are there any side effects & what are they?

Who would you like the medication stored with?

Allow child to keep medication on their persons and self-administer

Keep medication with responsible designated adult that will provide medications as necessary

N/A

Clear selection

Additional Information

What are some symptoms that a student may require immediate assistance? (eg coughing, sneezing, non-responsive to verbal/visual cues?) *

What are some triggers that can ‘bring on’ an emergency situation? (eg strobe lighting, ingestion of food allergic to) *

What does an emergency situation look like? *

What action should be taken during an emergency situation? *

Should medical transportation to a hospital be required after an emergency situation? *

Yes

Is there any other information we should be aware of? *

Send me a copy of my responses.

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