Individual Health Care Plan (IHCP)

Personal Information

Student Name

Date of Birth

Grade/Class

Parent/Guardian Name

Contact Number

Emergency Contact Information

Medical Diagnosis/Conditions

Allergies (if any)

Medications (during school hours)

Medical Procedures Required at School

Signs/Symptoms of Medical Emergency

Steps to Take in an Emergency

Daily Care Requirements

Special Instructions

Health Care Provider Information

Provider Name

Provider Contact Number

School Nurse/Staff Responsible

Parent/Guardian Signature

Date

School Nurse Signature

Date