Health Forms for Parents and Caregivers
Medical Forms
Download the forms that are required based on your health condition, medications, or the health requirements for enrolling at your school. Bring these forms to your health care provider and return them to your school. LEARN staff will review the forms and may contact the medical provider to clarify services required during school hours.
While these forms often say “physician,” they may also be completed by other medical providers (MD, DO, APRN or PA).
General Forms
Student Medical Information [ English & Spanish ]
Illinois Certificate of Child Health Examination [ English ]
Sports Physical – Pre-participation Examination [ English ]
Religious Exemption Form [ English ]
Consent for Release/Exchange of Student Records and Information [ English ]
Health Requirements
Minimum Health Requirements [ English | Spanish ]
Early Childhood Health Requirements (Ages 3-5) [ English ]
Medication Administration
Physician Request for Self-Administration of Medication [ English ]
Parent Request for Self-Administration of Medication [ English | Spanish ]
Physician Request for Administration of Medication [ English ]
Parent Request for Administration of Medication to a Student [ English | Spanish ]
Allergies
Physician Report on Child with Allergies [ English ]
Food Allergy Action Plan [ English | Spanish ]
Physician Statement for Food Substitution [ English| Spanish ]
Physician’s Request for Student to Carry an EpiPen [ English ]
Asthma
Physician Report on Child with Asthma [ English ]
Asthma Action Plan [ English | Spanish ]
Physician’s Request for Student to Carry an Inhaler [ English ]
Diabetes
Physician Report on Child with Asthma [ English ]
Dental
State of Illinois Proof of Dental Examination Form [ English | Spanish ]
Cardiac
Physician’s Report of Child with Cardiac Condition [ English ]
Medical Referrals – PT/OT/Health
Physician’s Referral for Physical or Occupational Therapy [ English ]
Medical Referral [ English ]
Seizures
Physician Report on Child with a Neurological Disorder [ English ]
Seizure Action Plan [ English ]
Vision
State of Illinois Vision Examination Report [ English ]
Ocular Report [ English ]
Other Health Conditions
Physician Report on Child with a Major Medical Condition [ English ]
