Health Forms for Students

A physical exam is a routine health check-up performed by a healthcare professional to assess a student’s overall health and wellbeing. For students, physical exams are required for enrollment and specific activities, such as sports participation.

Incoming Grade 9 students must submit a physical exam dated within one year of the first day of school. Transfer students must submit a physical dated within one year of starting at ETHS or provide valid medical records from a previous Illinois high school. Note: Students attending Summer School must submit their physical exam prior to the start of summer classes.

Child Health Examination Form: English | Spanish

Certificate of Child Health Examination Form

There are many different forms a parent or guardian might turn in with information on their student’s health. However, the Certificate of Child Health Examination Form is the only one that satisfies proper school immunization documentation requirements in accordance with state law.

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Physical Exams at ETHS

The School-Based Health Center (operated by Endeavor Health) located on-campus at ETHS offers physical exams and vaccines for students. Visit eths202.org/students/healthcenter to learn more. To schedule an appointment for your student, call (847)424-7265 or email healthcenter@eths202.org.

An immunization (also called a vaccine) is a shot that helps protect your child from serious diseases by strengthening their immune system. Immunizations are especially important in a school setting because they help prevent the spread of contagious illnesses and keep all students, staff, and families safer. 

For detailed information, visit the Illinois Department of Public Health website.

Immunization requirements

Students must complete all immunizations and submit documentation to ETHS prior to the first day of school. If claiming a religious exemption from immunizations, a Religious Exemption Form signed by a physician is required.

• Diphtheria, Pertussis (Whooping Cough), Tetanus (DTP/Td)
• Inactivated Polio
• Measles, Mumps and Rubella (MMR)
• Hepatitis B
• Varicella (Chicken Pox)
• Haemophilus Influenza, Type B (HIB)
• Conjugate Meningitis (MCV4)
• Recommended: HPV (human papillomavirus)

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Vaccines at ETHS

The School-Based Health Center (operated by Endeavor Health) located on-campus at ETHS offers physical exams and vaccines for students. Visit eths202.org/students/healthcenter to learn more. To schedule an appointment for your student, call (847)424-7265 or email healthcenter@eths202.org.

All students entering Grade 9 must have a dental exam completed by a licensed dentist within 18 months prior to May 15th of the current school year. 

Download this form and have it completed, signed and dated by your child's dentist.

Dental Examination Form

English  | Spanish

• Asthma Action Plan: Required annually for students with asthma.

• Medication Authorization Form: Required for any prescription medication to be taken during school hours. Submit completed form along with the medication in its original pharmacy container.

A medical exemption is permitted when a student cannot receive a required vaccination due to a medical condition. These exemptions must meet the following criteria:

• Certification by a Licensed Healthcare Provider: The child’s healthcare provider (MD, DO, PA, APRN) must provide a written statement specifying why the reason a vaccine is contraindicated for the student. For example, a medical exemption is granted if a vaccine poses a health risk due to a medical condition.
   
• Temporary or Permanent Exemptions: Medical exemptions can be temporary (for a short duration, such as after surgery or illness) or permanent (if the student has a lifelong contraindication to a vaccine).

Illinois allows religious exemptions to vaccination requirements. Parents/guardians must submit a Certificate of Religious Exemption Form, including a statement explaining how the vaccine conflicts with their religious beliefs. The form must also be signed by the child’s healthcare provider (MD, DO, PA, APRN). Exemptions are required for students entering Grade 9, or upon initial enrollment for transfer students.

Certificate of Religious Exemption Form

If your student needs to take prescription medication during the school day—whether on a regular schedule or temporarily for an illness or injury—a Medication Authorization Form must be completed and kept on file in the Nurses’ Office (N121).

This form is required for all prescription medications, as well as any medications prescribed for temporary illnesses or conditions. This includes medications such as antibiotics, ADHD medication, or treatments for chronic conditions. ETHS staff are not permitted to administer or supervise the self-administration of any medication—prescription or non-prescription—without a completed Medication Authorization Form on file. Forms must be updated each school year or anytime the medication or dosage changes.

Prescription medications must be stored in the Nurses' Office in their original, labeled pharmacy container. Students may not self-administer prescription medications unless special permission is granted by a healthcare provider. Medications will be administered by the school nurse or supervised by trained staff.

Whenever possible, students should take medications at home under the supervision of a parent or guardian.

Medication Authorization Form

Bring the completed form, along with any medication to be stored at school, to the Nurses' Office (N121). If you have questions or would like to speak with a nurse, call us at (847) 424-7260.

Some students may need to carry and self-administer medication during the school day, including emergency meds like asthma inhalers or EpiPens®, and over-the-counter meds like ibuprofen. These can be carried and used by the student without going to the nurse under specific conditions, outlined below:

Emergency Medications: EpiPens and Asthma Inhalers

Students may carry and self-administer an epinephrine auto-injector (EpiPen®) and/or an asthma inhaler only if the following requirements are met:

• A completed Medication Authorization Form is on file in the Nurses' Office (N121).

• For EpiPens: A healthcare provider’s written order is required.

• For inhalers: A parent/guardian signature and a copy of the prescription label are required.
   

Over-the-Counter (OTC) Medications

Students may also carry and use common over-the-counter medications (such as Advil or Tylenol) for minor issues like headaches, cramps, or seasonal allergies, provided that:

• The medication is in its original container.

• The parent/guardian is aware the student has it.

• The student does not share medication with others.

If your student has a potentially life-threatening allergy—such as an allergy to certain foods, stinging insects, latex, or other substances—please provide the following information to Evanston Township High School each school year:

Allergy Action Plan	An Allergy Action Plan with instructions from your child’s health care provider outlining what steps the school should take if your child has an allergic reaction. You may use one of the allergy plan templates provided below or submit a plan from your child’s doctor. Allergy & Anaphylaxis Action Plan  Food Allergy & Anaphylaxis Care Plan
Medication Details	Medication details for any prescribed treatment, such as an EpiPen®. Please also complete the Medication Authorization Form. The health care provider should indicate if your child is allowed to carry and self-administer the medication. Medication Authorization Form
Signatures Required	Signatures from both the health care provider and a parent/guardian are required on all forms.

Bring the completed forms, along with any medication to be stored at school, to the Nurses' Office (N121). If you have questions or would like to speak with a nurse, call us at (847) 424-7260.

In accordance with Illinois School Code (105 ILCS 5/22-30), ETHS must request an Asthma Action Plan each school year for any student diagnosed with asthma.

The Asthma Action Plan should include:

• Instructions from your child’s health care provider on how the school should respond if your child experiences asthma-related complications while at school. You may use the Asthma Action Plan provided below or submit one from your provider.

• Information about any prescribed asthma medication (e.g., an inhaler) that may be needed at school. Along with the action plan, please complete the Medication Authorization Form and return it to school. The provider should note whether your child is allowed to carry and self-administer the medication.

Both the health care provider and a parent/guardian must sign the Asthma Action Plan and the Medication Authorization Form.

Asthma Action Plan

Medication Authorization Form

Bring the completed forms, along with any medication to be stored at school, to the Nurses' Office (N121). If you have questions or would like to speak with a nurse, call us at (847) 424-7260.

Diabetes requires careful management of blood sugar through diet, medication, and monitoring. To ensure students’ health and safety at school, an updated Diabetes Management Plan must be submitted to the Nurses’ Office each year.

This plan outlines a student’s specific medical needs, blood sugar management, and any necessary accommodations. It helps staff respond quickly to emergencies and provide the support students need throughout the day.

By keeping this plan current and working together, we help students with diabetes stay safe, healthy, and ready to learn.

ETHS is committed to helping students recover from injuries while continuing to participate in school as fully and safely as possible. Whether your student has a broken limb, concussion, recent surgery, or other medical issue, our Health Services team works closely with families to coordinate care and accommodations.

Temporary Medical Conditions

If your student is on crutches, wearing a brace, sling, or cast, or has mobility limitations, please notify the Nurses’ Office so we can provide access support (elevators, extra passing period time, etc.).

Any prescription medication needed during the school day—such as pain medication or antibiotics—requires a signed Medication Authorization Form from both a healthcare provider and a parent/guardian.

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Concussion Protocol 

Students recovering from a concussion may be eligible for temporary academic adjustments. Contact the Nurses' Office to begin this process.

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Elevator Access

ETHS has four elevators available for students with medical needs who are unable to use the stairs. To request access:

• Submit the Elevator Key Permission Form.

• Provide a note from your child’s health care provider that includes:

  • The reason for elevator use

  • How long your child will need elevator access

Keys are issued by the Nurses’ Office (N121). Once approved, the elevator key is for your child’s use only and should not be shared.

Note: A $50 fee will be charged if the key is not returned.

Elevator Key Permission Form

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PE / Activity Medical Modifications

If a student is unable to participate in PE due to illness, injury, or surgery, they may be eligible for temporary modifications or a medical excuse.

To request a PE excuse or modification:

1. Submit both of the following to the Nurses’ Office (N121) in person or by email at nurses@eths202.org:

   • A medical note from a licensed health care provider

   • A completed PE Medical Modification Form
     These documents must outline the condition, any activity restrictions, and the expected duration.

2. The nurse will review the documents and issue a medical excuse.

3. The student must bring the medical excuse and form to their PE teacher for instructions on modified participation.

Depending on the medical documentation, students may be assigned to:

• PERC (PE Resource Center – Room W133) for cognitive instruction

• PASS (Physical Activity Student Support Center – Room G158) for adapted physical instruction

• A combination of both

Students must scan in daily to the assigned location during their PE period and complete assignments provided by PE staff. Once medically cleared, the student must return to their regular PE class on the specified return date.

In accordance with Illinois state law (HB5394), school districts are required to develop a Cardiac Emergency Response Plan (CERP) that outlines how school personnel should respond to sudden cardiac arrest or other life-threatening emergencies occurring on campus or during school-sponsored events.

At ETHS, the CERP is a vital part of our ongoing commitment to student safety and wellbeing. This plan clearly defines the steps to take in the event of a cardiac emergency—such as a heart attack or sudden cardiac arrest—to ensure a rapid, coordinated response.

Our goal is to provide a safe environment where staff are prepared and empowered to act swiftly in emergencies.

ETHS Cardiac Emergency Response Plan