"Cultivating whole-student wellness through quality care and community connections"
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General District Health Forms
M223 Emergency Health Information Form M223 Emergency Health Information Form (Spanish) District Health Requirements Letter to Parents State of IL School Physical Form State of IL School Dental Exam Form State of IL School Eye Exam Form Authorization for Administration of Medication Permit
M223 Emergency Health Information Form
M223 Emergency Health Information Form (Spanish)
District Health Requirements Letter to Parents
State of IL School Physical Form
State of IL School Dental Exam Form
State of IL School Eye Exam Form
Authorization for Administration of Medication Permit
Waivers
*Not necessary unless any of the exam forms above are incomplete*
State of IL Certificate of Religious Exemption State of IL School Dental Exam Waiver Form State of IL School Eye Exam Waiver Form
State of IL Certificate of Religious Exemption
State of IL School Dental Exam Waiver Form
State of IL School Eye Exam Waiver Form
Required Annual Forms for Health Conditions
Asthma
Asthma Action Plan Authorization for Administration of Medication Permit Individualized Healthcare Plan (IHP) written by school nurse
Asthma Action Plan
Individualized Healthcare Plan (IHP) written by school nurse
Diabetes
Diabetes Medical Management Plan (DMMP) provided from physician Hypoglycemia Emergency Action Plan Hyperglycemia Emergency Action Plan Authorization for Administration of Medication Permit Individualized Healthcare Plan (IHP) written by school nurse
Diabetes Medical Management Plan (DMMP) provided from physician
Hypoglycemia Emergency Action Plan
Hyperglycemia Emergency Action Plan
Food Allergy
Food Allergy & Anaphylaxis Emergency Action Plan Authorization for Administration of Medication Permit Individualized Healthcare Plan (IHP) written by school nurse
Food Allergy & Anaphylaxis Emergency Action Plan
Insect Sting Allergy
Anaphylaxis Emergency Action Plan Authorization for Administration of Medication Permit Individualized Healthcare Plan (IHP) written by school nurse
Anaphylaxis Emergency Action Plan
Seizures
Seizure Action Plan Authorization for Administration of Medication Permit Individualized Healthcare Plan (IHP) written by school nurse
Seizure Action Plan
Health Forms by Grade Level
Every Grade
M223 Emergency Health Information Form or M223 Emergency Health Information Form (Spanish)
M223 Emergency Health Information Form or
Pre-K
Kindergarten
State of IL School Physical Form State of IL School Dental Exam Form State of IL School Eye Exam Form
2nd Grade
6th Grade
State of IL School Physical Form State of IL School Dental Exam Form
9th Grade
12th Grade
Up-to-Date Vaccination Record with proof of vaccination against meningitis
If you have any questions regarding which forms are needed, please contact your student's school nurse or Kayla Richolson, Director of Health Services at kricholson@mail.meridian223.org.