YAC Leaders:

This form and letter should be handed to the parents/carers of any child with an allergy that involves the use of an Epi-pen.

At the same time you must contact YAC HQ so that we can organise specialist Epi-pen training for your Branch team. Until this training has been given, the child’s parent/carer should stay with them at Branch sessions in case the Epi-pen needs to be administered: this will ensure the child’s safety and meet the conditions of YAC’s insurance. You must make sure that the completed form is returned to you, kept with the rest of your Branch membership forms and brought to every meeting. As with membership forms, this form should be reviewed by the parents/carers every year.

This form can also be used if a volunteer at your Branch uses an Epi-pen. Again, this will give you the information that you need to best support them in case of emergency,

This is necessarily a long and detailed form. Please get in touch with YAC HQ if you’d like to talk it through before handing it to the parent/carer.

Dear Parent/Carer,

Thank you for informing us of your child’s medical condition. To help us to take care of your child during YAC sessions, and to meet the terms of our insurance, we ask parents/carers of a child with a specific medical condition to complete a Healthcare Plan.

Please complete the enclosed Healthcare Plan with the assistance of your child’s healthcare professional and return it to your YAC Branch Leader. If you would like to discuss the Healthcare Plan first, please talk to the Branch Leader or contact YAC head office on 01904 671 417 or by email at .

The Healthcare Plan will allow us to store details about your child that we will use to take care of them during YAC sessions and to help them in an emergency. It will help us to better understand your child’s individual condition. If your child carries an Epi-pen, the Leaders at your YAC Branch will be given specialist training in how to administer these as soon as possible. Until we have done this, we will ask you to accompany your child at YAC sessions so that you are able to help them in an emergency.

Please make sure that you let us know of any updates or changes to your child’s medical condition or medication. We will ask you to check the Healthcare Plan at least once a year. We will of course store your child’s Healthcare Plan privately and securely and only use it in the way that we have described here.

Thank you very much for your help with this, and I look forward to receiving your child’s Healthcare Plan.

Best wishes,

YAC Branch Leader

Healthcare plan: for YAC members and volunteers who use an Epi-pen
Child’s name:
Child’s date of birth:
Child’s home address:
Parent/carer’s details: this person will be contacted first in an emergency
Name:
Home telephone number:
Mobile telephone number:
Address, if different to child’s:
Second emergency contact, in case we cannot reach the first contact in an emergency
Name:
Relationship to child:
Telephone number(s):
Doctor’s surgery
Name of surgery:
Telephone number(s):
Clinic/Specialist contact
Name:
Telephone number(s):
Details of the medical condition
Medical diagnosis or condition (e.g. peanut allergy):
Signs and symptoms of this child’s condition:
Triggers or things that make the condition worse:
Routine healthcare requirements (e.g. dietary needs):
Emergency medication
Name and type of medication (as described on the container):
Dose and method of administration (how the medication is taken and the amount):
Are there any contraindications (signs that the medication should not be given)?
Are there any side effects that YAC Leaders should be aware of?
Can the child administer the medication themselves?
Yes [ ] No [ ] Yes, with supervision [ ]
Is any other follow-up care necessary?
Who should be notified if the medication is given?
Parents [ ] GP [ ] Specialist [ ]
YAC Branch team: list the people at your Branch trained to administer medication for this child:
Child and parent/carer agreement
I agree that the information contained in this plan may be shared with people involved in my child’s care (this includes the emergency services). I understand that I must notify the YAC Branch of any changes to the plan.
YAC Member’s signature: / Date:
YAC Member’s name:
Parent/carer’s signature: / Date:
Parent/carer’s name:
Healthcare professional agreement
I agree that this information is accurate and up-to-date.
Signed: / Date:
Name:
Job title:
Permission for emergency medication
I agree that my child can be administered with the medication outlined above in an emergency.
Parent/carer’s signature: / Date:
Parent/carer’s name:
Record of medication given
YAC volunteers will use this section to record any occasions when they administer your child’s medication. They will only administer the medication as described in this form and after they have been trained to do so.
Date / Time / Name of medication / Dose given / Any reactions? / Name of person administering / Signature