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 2014-15

Emergency Medical Record - 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 Emergency Medical Record 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 EMERGENCY MEDICAL RECORD BY AUGUST 1st, 2014. 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.

The Illinois Department of Public Health changed the Tdap vaccination requirement that began with the 2013-2014 school year. This requirement is as follows: all students entering, advancing, or transferring into 6th, 7th, 8th, 9th, 10th, 11th, or 12th grades will be required to show proof of receipt of one dose of Tdap vaccine (combined tetanus, diphtheria, acellular pertussis) vaccine regardless of the interval since the last DTap, DT or Td dose. This must be reported to the CLA Health Office by October 15th of the school year. To read the complete Illinois Department of Public Health Letter to Parents click here. To download a form to bring to your health care provider to report the administration of the Tdap, if it is not on your child’s current Certificate of Child Health Examination Form, click here: 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.

Medication Administration 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 (such as inhalers, diabetic medications, EpiPens, etc.) This form must be completed and signed by the licensed physician who prescribes this medication for you. PLEASE CHECK THE SPECIAL HEALTH CARE PLANS BELOW if your child has one of these conditions, download that form and take it with you to the doctor when you go to get the medication form authorized.

Non-prescription Medication Authorization form - for over-the-counter medications that the parent would like given. Please note: only three doses may be given for any one condition and then a doctor's prescription will be required stating the medical condition and the need to continue this medication.

Permission to Carry Medication & Medical Devices - 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):

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.

NEW: 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

Religious Exemption Letter

Eye Exam Waiver Form

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.


Food Allergy

Allergy (except food allergy)


Diabetic Care Plan & Blood Glucose Testing Care Plan


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

Book Order Forms


2014-15 CLA school book ordering is now available online.

Order Now: click here to order your 2014-15 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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