REV 2/2025

Medically Complex Foster Care Child-Specific Training

Please answer each question that applies in detail.
Date of child-specific training: 	

SECTION 1

Child’s name:
Child’s date of birth:

Name of individual receiving training:

Reason for child-specific training (select one):  New placement
 New medical condition Respite 
 Babysitting
 Other (list):

SECTION 2

Please list the child’s medical diagnoses and the treatment plan for each:
.

Additional information for a child with diabetes, seizures, or a feeding tube:

Training provider signature (Credentials if medical provider)

Date signed

Individual receiving training signature	Date signed

SECTION 3 (Complete only if applicable)
If the child has a diagnosis of diabetes (Type 1 or 2), seizures, or a feeding tube, please fill out the corresponding section.
Diabetes

Frequency of glucose checks/continuous glucose monitoring:

Carb to insulin ratio & correction factor:

Nighttime insulin dose:

Plan for hyperglycemia (check ketones, drink water, etc.):

Plan for hypoglycemia (juice, glucose tablets, etc.):

Seizures

Typical presentation of the child’s seizure:

Anti-seizure medication (dose/frequency):

Seizure action plan (emergency seizure medication/instructions):

Additional info: if the youth is diabetic, has seizures, or a feeding
tube:

G-tube (includes NG and GJ-tubes)

Feeding/formula (including free water):

Frequency and rate of feedings:

                                                         			                              
Training provider signature	Date signed (Credentials if medical provider)

                                                            		                               
Individual receiving training signature	Date signed