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2012 YMCA of WNC Hendersonville Branch Individualized Care Plan Form

This form is used by the YMCA of WNC Hendersonville Branch to document a child's prescription medications, special needs, or disabilities when participating in YMCA programs. It collects information such as the child's name and date of birth, medication name and dosage instructions, prescribing provider's contact details, and parent authorization. For special needs, the form requests an explanation so staff is informed before the child attends. All children are subject to the YMCA's disciplinary procedures, and a meeting may be scheduled to discuss specific needs, though some circumstances may constitute an undue hardship on the program.

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34 views1 page

2012 YMCA of WNC Hendersonville Branch Individualized Care Plan Form

This form is used by the YMCA of WNC Hendersonville Branch to document a child's prescription medications, special needs, or disabilities when participating in YMCA programs. It collects information such as the child's name and date of birth, medication name and dosage instructions, prescribing provider's contact details, and parent authorization. For special needs, the form requests an explanation so staff is informed before the child attends. All children are subject to the YMCA's disciplinary procedures, and a meeting may be scheduled to discuss specific needs, though some circumstances may constitute an undue hardship on the program.

Uploaded by

ymcawnc
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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2012 YMCA of WNC Hendersonville Branch

Individualized Care Plan Form


This form will be utilized when a parent/guardian has indicated on the Youth Information Form that
their child will be taking a prescription medication, has a special need and/or disability while
participating in the YMCA program.

________________________________________________________________________

MEDICATION INFORMATION:
CHILDS NAME: __________________________ CHILDS DATE OF BIRTH ___/___/____
Name of Prescription Medication to be taken at the YMCA: _________________________
Expiration Date: ___/___/____
Time(s) to Be Taken and Frequency: ___________________________________________
Dosage Amount: _________________________________
Beginning Date: ___/___/____

Ending Date: ___/___/____

Special Instructions: ______________________________________________________


________________________________________________________________________
Possible Reactions: ________________________________________________________
________________________________________________________________________
Prescribing Provider: _______________________________ Phone: ________________
Pharmacy: _______________________________________

Phone: ________________

I give the YMCA staff authorization to give medicine noted above and to call the health care provider
if needed.
Parent/Guardian Signature: ________________________________ Date: ___/___/____

SPECIAL NEED/CONCERN/DISABILITY:

If you listed a special need or medication on the previous sheet, please explain so our staff is familiar
with your childs situation prior to your child attending our program:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
If the YMCA staff and/or the parents/guardians feel it is necessary, a meeting will be scheduled in
advance to discuss specific information. The YMCA program welcomes all children to the extent that
it is reasonably able to do so. A child who requires measures that constitute a fundamental
alteration to the program or other undue hardship, or a child that poses a direct threat to the health
and safety of others, will not be able to participate in the program. All children, regardless of their
circumstances, are subject to YMCA disciplinary procedures.

________________________________________________________________________
Office Use Only: ____YMCA is to contact family regarding admission into camp
____ Parent requests contact with YMCA staff prior to camp

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