Health Requirements & Forms

  • State of Illinois law requires school districts to have certain health information on file for students entering a specific grade including verification of immunizations as well as physical, dental, and eye examinations. Students who do not have a current physical exam and immunization records on file will be excluded from school (including summer school) until all health requirements are met.

    A complete list of physical examination and immunization requirements is available on the Health Requirements for Grades 9-12 page. Below are many of the forms you and your health care provider will need in order to meet these requirements. To discuss health requirements or forms with a school nurse, call (847) 424-7260.

Illinois Health Forms

  • Illinois Certificate of Child Health Examination Form

    State of Illinois law requires proof of a physical examination dated no earlier than one year prior to a student entering grade 9, for all students entering the district for the first time, and for all students entering District 202 from outside the State of Illinois or the United States. Proof of physical exam and immunization dates and records must be submitted on the Child Health Examination Form. Download this form and have it completed, signed, stamped and dated by your child's health care provider.
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  • Illinois Certificate of Religious Exemption Form

    Religious Objections to Immunizations and/or Examinations: 

    As of October 16, 2015, parents or guardians requesting a religious exemption must submit the Illinois Certificate of Religious Exemption form signed by parent and the student’s health care provider. A completed and signed form must be on file prior to the start of school for any family seeking an exemption.
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  • Illinois Dental Examination Form

    In compliance with Illinois Public Act 093-0946, by May 15th of that school year, students entering grade 9 are required to have a dental exam on file. School dental examinations must have been completed within 18 months prior to the May 15 deadline. Download this form and have it completed, signed and dated by your child's dentist.
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  • Illinois Eye Exam Form / Vision and Hearing Screenings

    The Illinois School Code 410 ILCS 205/3 requires that a child has an eye exam by an optometrist or physician (such as an ophthalmologist) who provides eye examinations prior to entering kindergarten or entering a public, private or parochial school for the first time and no later than their first year in public school. Vision and hearing screenings are completed at 911ÖÆÆ·³§ annually for all students in special education and for all students new to the district. Vision or hearing screenings may also be requested by a parent, student, teacher or staff member.

     
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Asthma Action Plan

  • Asthma Action Plan

    The Illinois School Code 105 ILCS 5/22-30 requires Evanston Township High School to request an Asthma Action Plan (AAP) from parents/guardians of students with asthma each school year. You may elect to use the plan provided here by the American Lung Association, or one from your own health care provider. The action plan requires a signature from both the health care provider and the parent/guardian.
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Medication Authorization Form

  • Medication Authorization Form

    To gain authorization for a new medication or change in medication, submit the Medication Authorization Form along with the prescription medication in its original container from the pharmacy to the school nurse at the beginning of the school day. This can also be done prior to the start of the school year for routine medications. Download this form and have it completed, signed and dated by the health care provider who prescribed the medication.
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