Parent Medical Action Plan

If your child has a severe allergy or medical condition please fill out this form to inform our volunteers in case of an emergency. If you wish to make changes to this plan at any time please contact office@calvarygravenhurst.com and one of our Plan To Protect team members will get in touch with you.

 

Please complete the form below

Parent Name *
Parent Name
Parent Name
Parent Name
Child Name *
Child Name
Date *
Date
Emergency Phone Number *
Emergency Phone Number
Please list the best number to contact you in case of an emergency.
Please describe in detail your child's medical condition including triggers, signs, symptoms & reactions.
Please indicate clearly and concisely how our volunteers can best care for your child in the event that an incident occurs.
Doctor's Name *
Doctor's Name
Doctor's Phone Number *
Doctor's Phone Number
I consent to this information being shared with essential ministry personnel.
I consent to this information being transferred to a medical information poster and posted in key areas such as in the Child's Classroom, Kitchen or Office.