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JEF – Junior Elysian Farmers

Elysian Health, Medication and Healthcare Plan Form (Consent Pack Part 3)

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Participant Name

First

Last

Date of Birth

medication participant Possible

Parent/Carer Name (if under 18)

First

Last

Email Address

Telephone Number

Please describe all medical conditions.

Diagnoses.

Disabilities.

Allergies.

Dietary requirements.

Any recent medical concerns.

Any relevant hospital treatment.

Does the participant require medication during Elysian activities?

Yes
No

Medication name.

Medical condition being treated.

Dosage.

When medication should be taken.

Method of administration.

Expiry date.

Storage requirements.

Possible side effects.

What should staff do if medication is missed?

Can the participant self-administer?

Yes
No

Does medication require supervision?

Yes
No

Does medication require administration by staff?

Yes
No

Does the participant carry emergency medication?

Yes
No

Name of emergency medication.

Where it is kept.

When it should be used.

Emergency procedure.

Who should be contacted.

Does the participant already have a Healthcare Plan?

Yes
No

Diagnosis.

Triggers.

Symptoms.

Early warning signs.

What helps.

What should staff avoid.

Anything staff should know to help keep the participant safe.

Anything likely to trigger distress or illness.

Any additional support or adjustments required.

Checkboxes

I confirm that the health and medical information provided is accurate and complete.
I will inform Elysian of any changes to medical conditions, medication, allergies or support needs.
Third ChoiceI give permission for Elysian to administer or supervise medication in accordance with the information provided where necessary.
I will ensure all medication provided to Elysian is clearly labelled, in date and supplied in its original packaging.
I understand that Elysian may request further medical information or decline participation if it is not possible to safely meet the participant’s needs.
I consent to Elysian sharing relevant medical information with healthcare professionals or emergency services where necessary to protect the participant’s health, safety or wellbeing.

Name of person Completing the form *

First

Last

Your relationship to the participant

Signature

Clear Signature