Student Health Records Submission Form

1

Student's InformationPlease enter your student's information.

Student's Name

Student's ID Number

Student's School

Student's Grade

Type of Record

2

Before submitting your student’s physical, please confirm that each portion of the form is filled out. Incomplete forms will not be accepted.

Frequently missed areas include:

Parent questionnaire portion on the backside of the Illinois State Physical Form including parent signature
Healthcare Provider’s signature or stamp
Complete and legible dates

Please click 'Next" once you have confirmed all areas are completed.

3

Before submitting your health forms, please confirm that each portion of the form is filled out. Incomplete forms will not be accepted.

Frequently missed areas include:

Please click 'Next" once you have confirmed all areas are completed.

4

File Upload* This field is required.

Drag and drop files here

Select files to upload