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Student Accident Insurance

 Health Requirements by Grade

 Health Forms

Permission to Self-Administer Asthma Medication and Epinephrine Auto-Injector.pdf
Permission to Self-Administer Asthma Medication and Epinephrine Auto-InjectorUse SHIFT+ENTER to open the menu (new window).
Athletic Participation Fee and Waivers.pdf
Athletic Participation Fee and WaiversUse SHIFT+ENTER to open the menu (new window).
Interscholastic Parent Permission and Concussion Information.pdf
Interscholastic Parent Permission and Concussion InformationUse SHIFT+ENTER to open the menu (new window).
Allergy History Form.pdf
Allergy History FormUse SHIFT+ENTER to open the menu (new window).
Individual Health Care Plan (IHCP).pdf
Individual Health Care Plan (IHCP)Use SHIFT+ENTER to open the menu (new window).
Food Allergy Emergency Care Plan.pdf
Food Allergy Emergency Care PlanUse SHIFT+ENTER to open the menu (new window).
Permission to Administer Over-the-Counter Medication Form.pdf
Permission to Administer Over-the-Counter Medication FormUse SHIFT+ENTER to open the menu (new window).
Permission to Administer Prescribed Medication Form.pdf
Permission to Administer Prescribed Medication FormUse SHIFT+ENTER to open the menu (new window).
Dental Examination Form.pdf
Dental Examination FormUse SHIFT+ENTER to open the menu (new window).
Dental Examination Waiver Form.pdf
Dental Examination Waiver FormUse SHIFT+ENTER to open the menu (new window).
Optional Student Accident Insurance for Families.pdf
Optional Student Accident Insurance for FamiliesUse SHIFT+ENTER to open the menu (new window).
IESA Pre-Participation Examination Form.pdf
IESA Pre-Participation Examination FormUse SHIFT+ENTER to open the menu (new window).
Certificate of Child Health Exam rev. 1-12.pdf
Certificate of Child Health Exam rev. 1-12Use SHIFT+ENTER to open the menu (new window).
Eye Examination Report.pdf
Eye Examination ReportUse SHIFT+ENTER to open the menu (new window).
Eye Examination Waiver Form.pdf
Eye Examination Waiver FormUse SHIFT+ENTER to open the menu (new window).

 Health Information Documents

Field Trip Assessment Questionnaire.pdf
Field Trip Assessment QuestionnaireUse SHIFT+ENTER to open the menu (new window).
Field Trip Permission Form.pdf
Field Trip Permission FormUse SHIFT+ENTER to open the menu (new window).
FAQ About Tdap Vaccine.pdf
FAQ About Tdap VaccineUse SHIFT+ENTER to open the menu (new window).
Tdap Vaccination Update from Illinois DPH.pdf
Tdap Vaccination Update from Illinois DPHUse SHIFT+ENTER to open the menu (new window).
Guidelines for Prevention of Heat-Related Illness in Schools.pdf
Guidelines for Prevention of Heat-Related Illness in SchoolsUse SHIFT+ENTER to open the menu (new window).
Head Lice Infestation Fact Sheet.pdf
Head Lice Infestation Fact SheetUse SHIFT+ENTER to open the menu (new window).
Treating Head Lice.pdf
Treating Head LiceUse SHIFT+ENTER to open the menu (new window).
Board Policy on Administering Medicine.pdf
Board Policy on Administering MedicineUse SHIFT+ENTER to open the menu (new window).
Board Policy on Communicable and Chronic Infectious Disease.pdf
Board Policy on Communicable and Chronic Infectious DiseaseUse SHIFT+ENTER to open the menu (new window).
Board Policy on Health and Dental Examinations.pdf
Board Policy on Health and Dental ExaminationsUse SHIFT+ENTER to open the menu (new window).

 Links

  Illinois State Board of Education Guidelines for Managing Life-Threatening Food Allergies in Illinois Schools
  Center For Disease Control Head Lice Guidelines
  U.S. National Library of Medicine: Lice Information

 Food Allergy Management in District 109

Members of the Food Allergy Management Plan Development Committee presented the plan to the Board of Education on August 25, 2014. The plan is the most up-to-date of its kind in the state of Illinois.


Parents of students with food allergies and other related conditions may need to submit some or all of the following forms (many of which are type-on forms). Please check with your school's nurse or assistant principal if you have questions about any of the forms:

 Immunizations and Examinations

Immunizations: In Illinois, children enrolled in any grade need proof of up-to-date immunizations. Beginning in fall 2014, hepatitis B vaccination is required for students entering sixth grade (instead of students entering fifth grade). Also, students must show proof of having received two doses each of the live rubella and mumps virus vaccines. Additionally, any child entering kindergarten, sixth grade or ninth grade for the first time must show proof of having received two doses of varicella (chickenpox) vaccine. As of fall 2012, the State of Illinois requires that all students entering grades 6, 7 and 8 provide proof of the Tdap immunization to protect against whooping cough. This immunization has been recommended for children 10 years and older for several years, and most local physicians have been including this as part of the immunization routine. Visit the Illinois State Board of Education website for a list of required immunizations.

Health Examination: All Illinois children enrolling in kindergarten and grade 6, and any student enrolling for the first time in an Illinois school, are required to have a completed Health Examination. The examination must have been performed within a year of the student’s start date. The form should be returned to the school nurse. Any child who has not returned the required documentation of a health examination will be excluded from school on October 15.

Dental Examination: All children in kindergarten, grade 2 and grade 6, and any student enrolling for the first time in an Illinois school, are required to have an oral health examination by a licensed dentist by May 15 of that current school year. The examination must have been performed within 18 months of the May 15 deadline. The completed form should be turned into the school nurse. 

Eye Examination: All children enrolling in kindergarten and any student enrolling for the first time in an Illinois school are required to have an eye examination performed by an optometrist or medical doctor who performs eye exams. Documentation of the examination must be on file with school nurse prior to October 15. The exam must be completed within one year.  

 Participation in Middle School Athletics

Before Tryouts: All students interested in participating in any interscholastic athletic activity must have the following forms on file with the school nurse (you only need to submit these forms once each school year):

After Joining a Team: Coaches will give each team member this Athletic Participation Form, which includes fee information, student accident insurance information and asks parents to provide emergency information.