A Child Medical/Physical Care Plan for Child Care form (JFS 01236) must be completed annually and kept on file at Care After School if your child has a medical condition that requires any of the following. One form per condition is required.

• Monitoring the child for symptoms which require staff to take action

• Administration of medication or medical foods

• Procedures which require staff training

• Avoiding specific foods, environmental conditions or activities

• If your child carries and/or administers their own emergency medication

•  Directions on the form must match the prescription label.

• The original prescription label must be attached to the medication.

• Medications must be in the original container.

• If an over-the-counter medication is required, use the same language on the form as the medication bottle (do not write “Benadryl” on the form if it is a generic antihistamine).

• Be as specific as possible, do not use vague language such as “as needed” 

• Multiple medications for the same condition can be included on the same form

• See our sample forms  for common conditions below for reference.

A doctor’s signature is required only if:

• the prescription label is more than a year old, 

• you have a sample medication, or

• the dosage for your child is more than the medication box instructions for their age/weight

Because of our licensing requirements, we cannot accept the same forms that were provided to the school nor can we share medications with the school nurse’s office.

See below for completed sample forms for allergies, asthma, and type 1 diabetes. You may download and edit these forms specific to your student. There is also a blank form available if these conditions do not apply.