Christian Liberty Academy

Documents and Forms

 

 

Medical Forms

 

Copies of these forms can be found outside of the Nurse's Office. Please ask the nurse for care plans. Thank you for your cooperation as we work toward the accreditation that you have requested. In accordance with accreditation requirements, these are the forms that we need to have completed. Please submit them by the dates noted.

Medical Enrollment Requirements 2016-17

Online Health and Contact Forms & Required Exams:

Every parent must have a ParentsWeb Account in order to complete the online Family Demographics and Health Forms. Click here to view the tutorial: http://www.christianlibertyacademy.com/images/documents/renWebTutorial.pdf

Every student must have yearly updated online Family Demographics and Health Forms Please complete these forms on the ParentsWeb under the section called “Web Forms” by August 1st, or immediately upon registration, if you come in and register later than that. Please note: this must be done in order to receive report cards or progress reports. 

View ParentsWebVideo

Certificate of Child Health Examination - required for preschool, junior and senior kindergarten (must be done after the age of 4), sixth (6) grade, and ninth (9) grade students and new incoming students grades PS to 12 and submitted before October 15 of the school year. ALL students must have this on file and will be required to get one if they do not have the most up-to-date physical exam form on file. All physical exams shall be signed by a physician licensed to practice medicine in all of its branches, an advanced practice nurse who has a written collaborative agreement with a collaborating physician that authorizes him/her to perform health examinations, or a physician assistant to whom has been delegated the performance of health examinations by his/her supervising physician. (Section 27-8.1(2) of the School Code) A physician is required to review and sign any portion of the Certificate of Child Health Examination completed by a registered nurse who is not an advanced practice nurse.

MENINGOCOCCAL CONJUGATE VACCINE (MCV4)
This requirement is for grades 6 & 12 grades. All students entering grade 6 must show proof of receiving one dose of meningococcal conjugate vaccine (MCV4) on or after 11 years of age. All students entering grade 12 must show proof of receiving two doses of meningococcal conjugate vaccine. If the first dose of MCV4 was administered after 16 years of age, then only 1 dose of MCV4 is required at grade 12 entrance.
Documentation of MCV4 Administration

 

VARICELLA (CHICKENPOX) VACCINE:
Progression of 2 Dose Varicella Vaccine Requirement for Completion by All grades (K-12) by 2019 (Underlined Grade Level Indicates 2 doses required)
2017-2018 K 1 2 3 4 5 6 7 8 9 10 11 12
2018-2019 K 1 2 3 4 5 6 7 8 9 10 11 12
2019-2020 K 1 2 3 4 5 6 7 8 9 10 11 12


Tdap VACCINE:
Illinois Department of Public Health rules adopted in September 2011 now mandate that all students currently enrolled in grades six through twelve, shall show proof of receiving one dose of Tdap (defined as tetanus, diphtheria, acellular pertussis) vaccine regardless of the interval since the last Dtap, DT or Td dose.

Documentation of Tdap Administration

Dental Exam Form - required for all senior kindergarten, second (2) grade, and sixth (6) grade students and new incoming students grades K to 8. Dental Examination must be performed by a licensed dentist and submitted prior to May 15 of the school year. Dental exams must be completed within 18 months prior to the May 15 deadline.

Vision Exam Form - (eye exam - 2 pages; on page 2 please write in child's name and date of birth at the top if you are going to fax it in on 2 pages) - required for all senior kindergarten students and new incoming students grades K to 8 - must be performed by a licensed optometrist within one year prior to the first day of school and submitted before October 15 of the school year.

 

Medication Authorization Form – due by the 1st day of school - required by all students who require the administration of medication at school either daily or on an as-needed basis. This form must be completed and signed by the licensed physician who prescribes this medication for you as well as the parent.
This form includes authorization for the self-administration of inhalers and EpiPens.

 

For all grades 5 to 12 athletes participating in team sports (fall sports will be due during the summer BEFORE starting practice for fall sports teams):

  IHSA Sports Physical Form
IHSA Sports Medicine Consent and Acknowledgement


For grades 6 & 9 athletes:
the Certificate of Child Health Examination (above) that your doctor completes must also be completed with immunization information as part of your sports physical exams – the IHSA physical exam is not acceptable for the 6th and 9th grade physical because it is not a complete exam according to the Illinois Department of Public Health.

As of 2014-15: As part of the Concussion Bill that was signed by Governor Quinn, it is now a requirement for every school to have a signed concussion form on file for every student-athlete competing at their school.

Please Note: A religious exemption is not accepted for the sports physical exams for any reason. If you think your child may participate in a team sport, please take these forms with you to your health care provider when you go for your yearly physical so that they are completed and done.

Waivers: If you cannot afford to have dental or eye exams, there are waivers available that can be submitted in place of the dental and eye exams:

Dental Waiver Form

Eye Exam Waiver Form

Religious  Exemption Instructions - We do not force anyone to have immunizations that they object to.  We believe that the health of the child is the responsibility of the parent.  You may write and submit a religious exemption letter.  After October 16, 2015 the State of Illinois requires the use of their form titled “Illinois Certificate of Religious Exemption To Required Immunizations And/Or Examinations Form.  There is a section that must be completed by your Health Care Provider and signed that states the health care provider has provided information on the benefits and the health risks of immunizations.

SPECIAL HEALTH CARE PLANS: Due by the 1st day of school - If your child has one of these conditions and requires nursing care at school, please download the form take it to the doctor for completion.

ADD / ADHD Care Plan  
Please note: Medication Authorization Form is also required for students requiring medication at school.

Food Allergy and Anaphylaxis Emergency Care Plan  
Please note: Medication Authorization Form is also required for students requiring medication at school.

Asthma Action Plan  
Please note: Medication Authorization Form is also required for students requiring medication at school.

Diabetic Medical Management Plan  
Please note: Medication Authorization Form is also required for students requiring medication at school.

Seizure Action Plan  
Please note: Medication Authorization Form is also required for students requiring medication at school.

Acute Concussion Evaluation Care Plan  
Please note: Medication Authorization Form is also required for students requiring medication at school.

Individual Health Care Plan for other in-school nursing needs not addressed in the care plans above.  
Please note: Medication Authorization Form is also required for students requiring medication at school.

 

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