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Student Health Exam and Immunization

Please provide the required medical and dental forms by October 15, 2022. Required fields marked with an asterisk *

If you have any questions or concerns, please reach out the the administration office by calling (773) 891-5130 or emailing [email protected].

Contact Information

Student First Name*

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Student Last Name*

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Grade Entering*

Number Required

Please upload your student's most recent Child Health Exam + Immunizations Form provided by your pediatrician.

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Please upload your student's most recent Dental form provided by their dentist.

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Please upload your student's most recent Eye exam form provided by their Optometrist.

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Submitting Parent/Guardian First and Last Name*

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Submitting Parent/Guardian Email*

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Date Submitted*

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