Individual Care Plan for Child in Child Care

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Individual Care Plan for Child in Child Care

Transcript Of Individual Care Plan for Child in Child Care

Individual Care Plan for Child in Child Care
Plan must be updated annually or when there is a change in the child’s special need

Child’s Full Name

Today’s Date

CONTACT INFORMATION Parent’s/Guardian’s Name

Telephone

Parent’s/Guardian’s Name

Telephone

Primary Health Care Provider

Telephone

Specialist (if applicable)

Telephone

Specialist (if applicable)

Telephone

CHILD’S SPECIAL NEEDS Diagnosis, if known:

Known symptoms and triggers:

Describe activity, behavioral, or environmental modifications that are needed for the child:

Allergies (other than food allergy):
For food allergies or special dietary needs due to a health condition - must obtain written instructions from child’s health care provider (use page 3 of this form or health care provider’s form) MEDICATIONS (Medication Authorization Form must be completed for each medication.) List medication to be given at scheduled times, and how medication is to be given.

List medication to be given during an emergency, and how medication is to be given. Describe symptoms that would trigger emergency medication.

INDIVIDUAL CARE PLAN FOR CHILD IN CHILD CARE DCYF 15-970 (REV. 08/2019) EXT

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Individual Care Plan for Child in Child Care
Plan must be updated annually or when there is a change in the child’s special need
EMERGENCY RESPONSE PLAN List the steps and procedures the early learning provider should perform during an emergency related to your child’s special need.

SUGGESTED TRAINING FOR STAFF List suggested special skills training/education for the early learning program staff.

SUPPORTING DOCUMENTATION Please attach supporting documentation to this Individual Care Plan, including any existing individual educational plan (IEP), individual health plan (IHP), 504 plan, or individualized family service plan (IFSP). WAC 110-300-0300 requires an early learning provider to have supporting documentation of the child’s
special needs provided by the child’s licensed or certified: (i) Physician or physician’s assistant (ii) Mental health professional (iii) Educational professional (iv) Social worker with a bachelor’s degree or higher with a specialization in the individual child’s needs; or (v) Registered nurse or advanced registered nurse practitioner.
SIGNATURES

________________________________________ Parent or Guardian Signature ________________________________________ Early Learning Provider Signature
________________________________________ Health Care Provider Signature
(recommended)

________________________________________ Date ________________________________________ Date
________________________________________ Date

This section to be completed by child’s parent or guardian, if applicable:
I hereby give permission for _______________________________________________ to provide
(name of visiting health professional or specialist)
services to my child at this early learning program.

_____________________________________________________
Parent or Guardian Signature

________________________________________
Date

INDIVIDUAL CARE PLAN FOR CHILD IN CHILD CARE DCYF 15-970 (REV. 08/2019) EXT

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Individual Care Plan for Child in Child Care
Plan must be updated annually or when there is a change in the child’s special need

FOOD ALLERGY and/or SPECIAL DIETARY REQUIREMENTS
This page must be completed and signed by the child’s health care provider and parent or guardian.

Child’s Full Name:

Today’s Date:

Food the child must not consume (list each food separately)

Appropriate substitute food(s)

Describe allergic reactions and symptoms associated with this child’s particular allergies.
Describe the treatment plan for the early learning provider to follow in response to child’s allergic reaction (include names of medication, dosage amount, and directions for how to administer medication).

Other special dietary requirements due to a health condition.

______________________________________ Health Care Provider Signature
______________________________________ Parent or Guardian Signature

_____________________________ Date
_____________________________ Date

INDIVIDUAL CARE PLAN FOR CHILD IN CHILD CARE DCYF 15-970 (REV. 08/2019) EXT

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ChildCare PlanMedicationChangeDocumentation