The National Institutes Of Health's "National Diabetes Education Program"

Effective Dates:

This plan should be completed by the student’s personal health care team and parents/guardian. It should be reviewed with relevant school staff and copies should be kept in a place that is easily accessed by the school nurse, trained diabetes personnel, and other authorized personnel.

Student’s Name:__________________________________________________

Date of Birth: ____________________________________________

Date of Diabetes Diagnosis: ___________________________

Grade: _______________________________________________

Homeroom Teacher: ____________________________________

Physical Condition: _______Diabetes type 1_______Diabetes type 2

Contact Information

Mother/Guardian: ________________________________________________

Address: __________________________________________________

Telephone:_________________________________________________

Home: _________________________________________________

Work:___________________________________________

Cell: _______________________________________________

Father/Guardian:________________________________________________

Address: ________________________________________________

Telephone: __________________________________

Home: _________________________________________

Work Cell: ______________________________________

Student’s Doctor/Health Care Provider:__________________________________________

Name: ___________________________________________

Address _______________________________________

Telephone:_____________Emergency Number: ___________

Other Emergency Contacts:

Name: ______________________________________________

Relationship: _____________________________________

Telephone: ___________________________________

Home:_________________________________________

Work:________________________________________

Cell: ________________________________________

Notify parents/guardian or emergency contact in the following situations:

___________________________________________________________

___________________________________________________________

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