Embedded Files
child-health-exam-form-revised-01-31-2024.pdfChild Health Exam Form
Dental Exam.pdfProof of Dental Exam Form
Illinois_Certificate_of_Religious_Exemption.pdfReligious Exemption Form
Important Forms
Important Forms
The original Illinois Certificate of Child Health Examination Form must be on file with the MVTHS Nurses' Office before September 15th to avoid exclusion from school.
If a religious exemption is requested for these requirements, the Illinois Department of Public Health and Illinois State Board of Education requires that an Illinois Certificate of Religious Exemption Form be completed by a parent/guardian and signed by your child's healthcare provider. The original form must be on file with the Nurses' Office.
Additional Required Health Documents are uploaded below. If any of these apply to your student please complete the forms and submit them via the link.
Additional Required Health Documents
Additional Required Health Documents
Allergy & Anaphylaxis Action Plan (for any type of serious allergic reaction)
Food Allergy & Anaphylaxis Care Plan (specific for food allergies)
Asthma Action Plan (AAP) - The Illinois School Code 105 ILCS 5/22-30 requires Mount Vernon Township High School to request an Asthma Action Plan (AAP) from parents/guardians of students with asthma each school year.
Medication Authorization Form - Parents/Guardians have the primary responsibility for administering their child's medication and it should be given at home whenever possible by the parent or guardian. If it is necessary for a student to take medication during school hours or at school-related activities in order to assume full participation in the school program, the student’s parent or legal guardian must provide a completed, signed, and dated Medication Authorization Form providing for the administration of medication to the student during regular school hours. To gain authorization for use of prescription or OTC (over the counter) medication during the school day, submit the Medication Authorization Form along with the medication in its original container from the pharmacy to the school nurse. Medication authorization forms are required to be renewed every school year. Please ensure that you complete and submit the necessary paperwork at the start of the upcoming school year to avoid any interruptions in medication administration for your child.
Diabetes Management Plan- Please have the student’s health care provider complete the diabetes management plan. Each student with a diagnoses of diabetes will be responsible for bringing their own supplies to the Nurses’ office and replenish those supplies as needed.
Emergency Contact Form- Current parent/guardian and emergency contact
information must be up to date with the school. Although this information is
provided at the time of registration, the nurses office keeps this information on
file in case of emergency.
2025 OTC MED FORM.pdfOver the Counter Medication Form (As Needed)
Daily Prescribed Medication Auth Form.pdfDaily Prescribed Medication Authorization Form
Asthma_Action_Plan.pdfSeizure Action Plan.pdfDiabetes-Action-Plan.pdfOnce documents have been completed and signed by parent/guardian and healthcare provider, the form
must be submitted to the Nurse's office in one of the following ways.
• Mail:
Mount Vernon Township High School
Nurses’ Office
11101 Wells Bypass
Mount Vernon, IL 62864
• Fax: 618-246-1767
• In Person: Forms may be dropped off to the Nurse’s Office or the Attendance office in a sealed envelope
marked Nurses’ Office.
• Scan and upload here:
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