The required health forms shown below are due to CHA by the first day a new student enters school. Please email the forms as attachments to Health Services with a subject line as follows: Health Forms – Last Name, First Name (for example: Health Forms – Doe, Susie)


New Students, Preschool:
◘ Physical Exam
  • Physical exam certificates must be dated within one calendar year prior to the date of entry.
  • To be considered valid, ALL three sections of your student’s Physical Exam Certificate must be completed and signed as follows:
  1. Health History (top section page 2) Completed, dated, and signed by parent
  2. Physical exam completed and signed by physician/practitioner 
  3. Immunization record completed and signed by physician or nurse – For information regarding immunizations, please refer to the Health Services page for the State of Illinois Immunization Requirements. (If your student does not receive immunizations, you must complete the Illinois Religious Exemption Form for Immunization found on the Health Services page. A new letter must be submitted each school year.)
◘ Special Medical Considerations (if needed)

If your student has a special medical condition that we should be aware of, and/or you would like them to be able to receive prescription or over-the counter medication as needed, authorization forms are required. Please review our Special Medical Conditions page, with links to the related forms on the main Health Services page:

  • Allergies
  • Emergency action plans
  • Prescription Medication Authorization
  • Over-the-counter (OTC) Medication Authorization (such as Tylenol, Benadryl, etc.)
New Students, Grades K-12:
◘ Physical Exam
  • Physical exam certificates must be dated within one calendar year prior to the date of entry.
  • To be considered valid, ALL three sections of your student’s Physical Exam Certificate must be completed and signed as follows:
  1. Health History (top section page 2) Completed, dated, and signed by parent
  2. Physical exam completed and signed by physician/practitioner 
  3. Immunization record completed and signed by physician or nurse – For information regarding immunizations, please refer to the Health Services page for the State of Illinois Immunization Requirements. (If your student does not receive immunizations, you must complete the Illinois Religious Exemption Form for Immunization found on the Health Services page. A new letter must be submitted each school year.)
◘ Dental Exam Form
  • Submit a copy of the most recent exam (required only for Grades K, 2, 6, and 9).
  • If you do not have an exam, you must schedule an appointment and submit documentation.
  • If the exam is not in the student’s file by 5/15/22, he/she will be excluded from school.
◘ Eye Exam Form
  • Eye exam forms must be performed, signed, and dated by an eye care specialist, ophthalmologist, or optometrist within one year prior to the first day of school.
◘ Additional Forms

All other grade level required health forms. Refer to the requirements by grade on the Health Services page.

◘ Special Medical Considerations (if needed)

If your student has a special medical condition that we should be aware of, and/or you would like them to be able to receive prescription or over-the counter medication as needed, authorization forms are required. Please review our Special Medical Conditions page, with links to the related forms on the main Health Services page:

  • Allergies
  • Emergency action plans
  • Prescription Medication Authorization
  • Over-the-counter (OTC) Medication Authorization (such as Tylenol, Benadryl, etc.)

Find links to all forms on the main Health Services page. You may wish to print this page out so you know which forms are needed for your student.

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