Scribd
Upload
21 views

YMCA of Western North Carolina Corpening Memorial Branch - Individualized Care Plan Form

This form is used by the YMCA of Western North Carolina Corpening Memorial Branch to document an individualized care plan for children who need prescription medication or have special needs while in their programs. It requests information about the child's medication including dosage, times to be administered, possible reactions, and authorization for staff to give the medication. The form also provides space for parents to describe any special needs or disabilities and allows for a meeting to further discuss the child's needs. It notes that all children must be reasonably accommodated but may be excluded if their participation poses an undue hardship or risk to others.

Uploaded by

ymcawnc
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as PDF, TXT or read online on Scribd
21 views

YMCA of Western North Carolina Corpening Memorial Branch - Individualized Care Plan Form

This form is used by the YMCA of Western North Carolina Corpening Memorial Branch to document an individualized care plan for children who need prescription medication or have special needs while in their programs. It requests information about the child's medication including dosage, times to be administered, possible reactions, and authorization for staff to give the medication. The form also provides space for parents to describe any special needs or disabilities and allows for a meeting to further discuss the child's needs. It notes that all children must be reasonably accommodated but may be excluded if their participation poses an undue hardship or risk to others.

Uploaded by

ymcawnc
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 1

YMCA of Western North Carolina

Corpening Memorial 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.
CHILDS NAME: ______________________________________________

CHILDS DATE OF BIRTH _______________________

Name of Prescription Medication to be taken at the YMCA:____________________________________________


Expiration Date: _____________ Time 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: _____________________

Parents/Guardians - Please note special needs, concerns and/or disabilities that are important for our staff to
be familiar with prior to your childs admittance into the program Please be specific.
_______________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
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.
____________________________________________________________________________________

You might also like