Date of Birth:
Section F – Authority to Act
This form authorises school staff to follow my/our advice and/or that of our medical practitioner. It is valid for one year or until I/we advise
the school of a change in my/our child’s health care requirements.
Medical Practitioner (if required):
Note: Where a doctor provides a written plan for staff to follow, this form may not need to be completed.
OFFICE USE ONLY
Is support to be provided by an education assistant?
If yes, name(s) of authorised staff:
Is specific staff training required?
Date of training:
Date of retraining
Type of training:
Name of person(s) to be trained:
If medical practitioner has indicated additional support is required, please specify authorised staff:
When completed please attach the Student Health Care Summary to the front of this document.
Form 9 Page 2 of 2