Transcription of State of Illinois Certificate of Child Health …
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State of Illinois Certificate of Child Health …
11/2015 (COMPLETE BOTH SIDES) printed by authority of the State of Illinois State of Illinois Certificate of Child Health Examination Certificates of Religious Exemption to Immunizations or Physician Medical Statements of Medical Contraindication Are Reviewed and Maintained by the School authority . Student s Name Last First Middle Birth Date Month/Day/Year Sex Race/Ethnicity School /Grade Level/ID# Address Street City Zip Code Parent/Guardian Telephone # Home Work IMMUNIZATIONS: To be completed by Health care provider.
11/2015 (COMPLETE BOTH SIDES) Printed by Authority of the State of Illinois
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