All Students:

Medication Authorization Form: Complete these forms 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 / guardian 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 Healthcare Provider. A Parent / Guardian must complete and sign the Health History section.

IDPH Dental Examination: The Illinois Department of Public Health (IDPH) mandates a dental examination for entry into ninth grade.

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 Healthcare Provider. A Parent / Guardian must complete and sign

the Health History section.

International or Transfer Students New to the State of Illinois:

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 Healthcare Provider. A Parent / Guardian must complete and sign the Health History section.

Illinois Eye Examination Report This is a two-page form.

Athletes:

IHSA Pre-Participation Form: All athletes must complete the ISHA Sports Physical form annually.

NOTE: this is a different form than what is required for admission. This form must be signed by your Healthcare Provider. A Parent/Guardian and Athlete must complete and sign the Health History section on page 1 of this form. Please email the completed form to the Athletic Department jbyrne@nddons.org or to the school nurse candersen@nddons.org . If the form is missing or incomplete the athlete will not be eligible for participation; practice or games, until corrected.

Seniors:

Must submit an Immunization Record with proof of Meningococcal vaccination (MCV4) on or after 16 years of age.

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.