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

First Name

Last Name

Parent Name

First Name

Last Name

Child Name

First Name

Last Name

Child's Age

Child's Weight

Child's Sex

Date

MM

DD

YYYY

Emergency Phone Number

Please list the best number to contact you in case of an emergency.

(###)

###

####

Email Address

Medical Condition

Please describe in detail your child's medical condition including triggers, signs, symptoms & reactions.

Action Plan

Please indicate clearly and concisely how our volunteers can best care for your child in the event that an incident occurs.

Doctor's Name

First Name

Last Name

Doctor's Phone Number

(###)

###

####

Parent Consent - Information Sharing

I consent to this information being shared with essential ministry personnel.

Parent Consent - Medical Poster

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.