The following forms must be submitted to the Clinic by August 1:

All Students:

Medication Authorization Form This must be completed annually and signed by both the parent/guardian and the student’s Healthcare Provider.

Freshmen:

IDPH Certificate of Child Health Examination: This is a mandated requirement of the Illinois Department of Public Health (IDPH) for entry into ninth grade. This 2-page form consists of the following sections: Immunizations, Physical Exam and Health History. This form must be signed by your Healthcare Provider and a Parent/Guardian must complete and sign the Health History section located on the top of page 2.

IDPH Dental Examination:  This is a mandated requirement of the Illinois Department of Public Health (IDPH) for entry into ninth grade.

Transfer Students:

IDPH Certificate of Child Health Examination: This is a mandated requirement of the Illinois Department of Public Health. This 2-page form consists of the following sections: Immunizations, Physical Exam and Health History. This form must be signed by your Healthcare Provider. A Parent/Guardian must complete and sign the Health History section.

IDPH Dental Examination:  It is a mandated requirement of the Illinois Department of Public health that Transfer Students (entering into the ninth grade only) have a  dental exam and complete the form.

International or Transfer Students New to the State of Illinois:

  1. IDPH Certificate of Child Health Examination: This is a mandated requirement of the Illinois Department of Public Health (IDPH).
  2. Illinois Eye Examination Report: This is a two-page form.
  3. IDPH Dental Examination: This is a mandated requirement of the Illinois Department of Public Health (IDPH) for ninth grade students only.

Athletes:

Before participating in any athletic activity at Regina Dominican, a student must have the following completed:

1.IHSA Pre-Participation Form: Must complete annually. Note, this is different form than what is required for admission. This is required for all athletes. This form must be signed by your Healthcare Provider. A Parent/Guardian and student must complete and sign the Health History section on page 1 of this form. Please email completed form to the Athletic trainer, kpszczola@rdpanthers.org. Please keep a copy of this form for your records.
2. Register for athletics on Final Forms. Here is a link that explains how to register:
https://s3-us-west-2.amazonaws.com/sportshub2-uploads-prod/files/sites/2281/2019/09/28134325/regina-dom-parent-playbook-.pdf
Both the parent and student-athlete will have to create a Final Forms account and sign documents electronically.
If there are any questions, please contact the Athletic Director, bmancuso@rdpanthers.org.

Seniors:

Current Immunization Record with proof of Meningitis vaccination on or after the 16 years of age (IDPH requirement).

Other Forms (If Applicable):

  1. Asthma Action Plan and/or Allergy Action Plan
  2. Medical Exemption to Immunization: This is an IDPH requirement. Requires a signed statement by your Health Care Provider delineating the specific contraindication to immunization and the expected duration.
  3. Religious Exemption to Immunization: This is an IDPH mandate. Requires the Parent / Guardian to complete the Illinois Certificate of Religious Exemption. This form must be signed by your Health Care Provider.

 

Please retain a copy of your student’s health records. If you have any questions please contact the clinic at 847-256-7660 ext. 248 or email the school nurse, Ms. Marti Barthel RN, at mbarthel@rdpanthers.org.