Health Forms

The following health forms are available for download. To request a physical copy or for additional information, contact school nurse Peggy Ziel by phone: 815-220-2738, email: pziel@lphs.net, or confidential fax number: 815-223-3507.

Certificate of Health Examination Form

• English
• Spanish

School Medication Authorization Form

• English
• Spanish

Eye Examination Waiver Form

• English

  Food Allergy Emergency Action Plan

• English

  Religious Exemption to Required Immunizations and/or Examinations Form

• English

  Asthma Action Plan & Medication Request Form

• English 

  Proof of Dental Examination Form

• English 

  Diabetes Medical Management Plan

• English