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 2015-16

Health Emergency Form - required for all students

A parent or guardian must complete the Emergency Medical Record. Please note: You do not have to go to your physician for this. The Health Emergency Form is the most important form that you need to fill out for the School Nurse, so that you can be easily contacted in an emergency. The up-to-date contact phone numbers and the signed emergency release on side two are essential in the event that we need to provide emergency medical care for your child in your absence. PLEASE RETURN THE HEALTH EMERGENCY FORM BY AUGUST 1st, 2015. If you are out of town at this time, please note that we must have this form no later than the orientation day.

Certificate of Child Health Examination (Certificate of Child Health Examination - Spanish version) - required for preschool, junior and new 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.

New Immunization Requirements

This new requirement will be for entry into grades 6 & 12 grades only. 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.
Documentation of MCV4 Administration

Progression of 2 Dose Varicella Vaccine Requirement for Completion by All grades (K-12) by 2019 (Underlined Grade Level Indicates 2 doses required)
2015-2016 K 1 2 3 4 5 6 7 8 9 10 11 12
2016-2017 K 1 2 3 4 5 6 7 8 9 10 11 12
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

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 12. 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 12 - 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.

Prescription Medication Request 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.

Self-Administration of Asthma Inhaler or EpiPen Request Form - due by the 1st day of school - for any student who will be carrying medication or a medical device during school - requires a doctor's signature.

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) tthat 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.

NEW 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.

Dental Waiver Form

Eye Exam Waiver Form

Immunization 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

Food Allergy and Anaphylaxis Emergency Care Plan

Asthma Action Plan

Diabetic Medical Management Plan

Seizure Action Plan

Acute Concussion Evaluation Care Plan

Individual Health Care Plan for other in-school nursing needs not addressed in the care plans above.

Book Order Forms


2015-16 CLA school book ordering is now available online.

Order Now: click here to order your 2015-16 CLA school books.

Instructions are included on each form. New families will receive forms upon registration. You may call Mrs. Mary Horstman at 847-385-2012 with any questions or concerns.

Paper book order forms are still available at dayschool office.

The video below shows how to use the online book ordering process.





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