Form 9 - Activity Of Daily Living Page 2
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1
2Name:
Date of Birth:
Year:
Form:
Teacher:
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.
Parent/Carer:
Medical Practitioner (if required):
Date:
Date:
Review Date:
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?
Yes
No
If yes, name(s) of authorised staff:
Is specific staff training required?
Yes
No
Date of training:
/
/
Date of retraining
/
/
Type of training:
Training providers:
Name of person(s) to be trained:
If medical practitioner has indicated additional support is required, please specify authorised staff:
Actions taken:
When completed please attach the Student Health Care Summary to the front of this document.
Form 9 Page 2 of 2
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Parent category: Medical