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

All Students:

Medication Authorization Form: Complete this form if your student is to take medication during the school day. This includes self-medication for Asthma inhalers, Epi-Pens, Insulin and over the counter medications stocked in the clinic (Ibuprofen, Acetaminophen, and Benadryl). This form must be signed by both the parent and your Health Care Provider.

Freshmen:

IDPH Certificate of Child Health Examination: The Illinois Department of Public Health (IDPH) mandates a physical 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 Health Care Provider. A Parent / Guardian must complete and sign the Health History section.

Transfer Students:

IDPH Certificate of Child Health Examination: This is an IDPH Mandate. This 2-page form consists of the following sections: Immunizations, Physical Exam and Health History. This form must be signed by your Health Care Provider. A Parent / Guardian must complete and sign the Health History section.

International or Transfer Students New to the State of Illinois:

  1. IDPH Certificate of Child Health Examination: This is an IDPH Mandate. This 2-page form consists of the following sections: Immunizations, Physical Exam and Health History. This form must be signed by your Health Care Provider. A Parent / Guardian must complete and sign the Health History section.
  2. Illinois Eye Examination Report: This is a two-page form.

Athletes:

IHSA Pre-Participation Form: This is required for all athletes. This form must be signed by your Health Care Provider. A Parent / Guardian must complete and sign the Health History section.

Seniors:

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

Other Forms (If Applicable):

  1. Asthma Action Plan and/or Allergy Action Plan
  2. Medical Exemption to Immunization: This is an IDPH mandate. 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 daughter’s health records. If you have any questions please contact the clinic at 847-256-7660 ext. 248