Enrollment and Registration Packet 2015-2016

Community High School District #99
North High School
Realizing Individual Potential for the World Community
School Year 2015-2016
Dear Parent/Guardian and Student,
Thank you for your interest in the enrollment and registration procedure at North High School.
To begin, you must inform the current school of your intent to leave and
complete their withdrawal process. It is your responsibility to request transfer records.


Refer to the Enrollment Check List to assist you in gathering the necessary documents. Omission of
any necessary documents will delay the enrollment process and course selection.
Complete the following enclosed forms:
 Student Information Form
 Release of Records
 Residency Affidavit
 Special Needs History Information
Upon review of the materials you have submitted, I will schedule a math assessment test and an
appointment for you and your student to meet with a guidance counselor. Be advised that the
enrollment process may include, but may not be limited to, the following: an interview with an
administrator, referrals from the previous schools, placement tests, and residency checks.
Welcome to North High School!
Ruth Schneider
Registrar
COMMUNITY HIGH SCHOOL DISTRICT 99 – NORTH HIGH SCHOOL
ENROLLMENT CHECK LIST
All documentation must be presented in acceptable form prior to making an appointment for enrollment.
Omission will delay your testing appointments and course selection.
If you would like to verify that your residence is within District 99 North or South attendance boundaries,
you may call the North High School registrar, review your address with the DuPage County Clerk’s Office, or check
our district website map at http://www.csd99.org/district-99/boundaries-maps-and-directions/
RESIDENCY DOCUMENTS
Required: one from Category A and two from Category B (proof from BOTH categories)
Please note: If the student’s family is not the owner/lessee of the District #99 address, additional forms are
required and can be obtained from the registrar.
•
•
•
•
Category A (one document showing a current District #99 address)
Real estate tax bill
Mortgage statement/Closing contract
Signed lease (with a contact phone number for the landlord/leasing agent)
Agreement of sale
•
•
•
•
•
Category B (two documents showing a current District #99 address)
Driver’s license (showing new District #99 address)
Home/apartment insurance
Public aid card
Utility bill within the past 2 months (excluding phone or cable)
Currently dated bank statement/Currently dated payroll stub
OTHER STUDENT DOCUMENTS
• Certified copy of student’s birth certificate OR student passport (if birth certificate is not available)
• Photo ID of parent or guardian
ADDITIONAL DOCUMENTATION
Specific situations may require further documentation to determine the residential custodian of the student based
on care or custody agreements. Please be prepared to share such documents, if requested.
DOCUMENTS THAT MUST BE OBTAINED FROM PREVIOUS SCHOOL
It is the parent/guardian responsibility to request transfer records.
1. ISBE Student in Good Standing transfer form from Illinois public schools.
2. An unofficial transcript for current high school students.
7th and 8th grade report cards and course recommendations for incoming freshmen.
3. A State of Illinois Certificate of Child Health Examination including immunizations with the physician’s signature
and address. A printout of immunizations does not meet this requirement.
 Incoming freshmen: a physical is required before the first day of school.
 Out-of-state transfers: immunizations must be provided, and an Illinois physical will be required.
4. Standardized test scores if available.
5. Current class schedule and grades in progress if transfer is occurring during the school year.
6. Current IEP for any student receiving Special Services at their previous school.
IMPORTANT INFORMATION REGARDING
MATH AND ENGLISH ASSESSMENT TESTING
All students new to North High School are required to take a Math and English
Assessment Test prior to the registration appointment with his or her counselor.
Students can sign up for the testing after all necessary
enrollment documents have been received by the registrar.
Summer Transfers: Test appointments will be scheduled on certain dates in August
and held from 8:30 to 10:30 a.m. Students should arrive at 8:20 am in the main office
on the day of their scheduled testing. They are allowed and encouraged to bring their
own calculators, as well as pencils, for the math assessment.
School Year Transfers: After August group-testing, students will need to sit for the
assessments on an individual basis. Test appointments will be scheduled on a daily
basis in the morning. Students should arrive at 7:45 a.m. in the Guidance office. A
minimum of 24 hours is needed between testing and your student’s counseling
appointment to allow for grading the tests and determining the appropriate course
recommendation.
PLEASE NOTE: If your student does not appear for the scheduled assessment tests,
the registration appointment will be forfeited. Also, if the student is late for the
assessment tests, he/she will not be admitted to the resource center for testing.
This will also result in the registration appointment to be cancelled.
Arrive at the appointed arrival time to avoid any delay in registration.
Arrangements will be made to reschedule the testing and registration appointments. If
the student misses his or her testing appointment, no guarantee can be made that he
or she will be able to attend the first day of classes.
Positively North
Welcome and Orientation!
INCOMING FRESHMEN AND TRANSFER STUDENTS
You are invited to join us for the Positively North High Welcome and Orientation!
The purpose of this day is to welcome you to North High, answer any questions you have, and show
you around the building. The North Star Leaders, who are members of the junior and senior classes,
have some great activities planned. We hope you can join us!
When:
Wednesday, August 19, 2015
Where:
We will meet at 7:45 a.m. in the lobby of the Purple Gym.
Use the Prince Street entrance.
Time:
The event will take place from 8:00 a.m. to 12:00 p.m.
Transportation: Students eligible for bus service will use their normal school bus route designated
for the year. Details of your specific route can be found in the packet that you will pick up on
Schedule Pick-Up Day, Monday, August 17. Arrive at your bus stop at that designated time. At
12:15 p.m., buses will leave North High and drop off back at your bus stop. Some of you may be
involved in extracurricular activities and may have practices and/or meetings after the orientation.
Please check with your coach or sponsor.
Please bring your schedule, locker number and locker combination, and dress comfortably for
the day’s activities. If you have any questions, please contact the Counseling and Student
Support Services Department at (630) 795-8400.
See you there!
2015-2016 School Year
ID # ____________________________
Office Use Only
STUDENT INFORMATION FORM
DISTRICT 99 - NORTH CAMPUS
Today’s Date ___________________________
Counselor ________ Dean _______ P/S _______
Bus _________
School of Origin _________
Entry Date ___________ Code ________
New Student  DGS  DGN  Reentry 
09 2019
STUDENT
10 2018
11 2017
12 2016
Last__________________________________ First_______________________ Middle Name________________
Nickname_____________________________
Birthdate______/______/______
Gender  M F
Race (Choice of one or more is required)
 (1) Native American/Alaskan Native
 (2) Asian
 (3) Black/African American
 (5) White
 (7) Native Hawaiian/Other
Pacific Islander
You must choose Yes or No Hispanic/Latino Ethnicity  Yes  No
Birthplace City___________________________State___________Country_____________________________
Last School Attended_____________________________________City_______________________State______
PARENT/GUARDIAN 1 Person the student lives with:
Last Name__________________________First Name_______________________Relationship to Student____________
Address_____________________________________Apt________
_________________________________ ____________
Home phone __________________________
Work _______________________ ext
_____
Zip
E-mail address_____________________________________
Cell
________________________________
PARENT/GUARDIAN 2 If guardian 2 lives at different address, please note address:
Last Name__________________________First Name_______________________Relationship to Student_____________
Address_____________________________________Apt________
_________________________________ ____________
Home phone __________________________
Work _______________________ ext
_____
Zip
E-mail address_____________________________________
Cell
________________________________
EMERGENCY CONTACT 1 (other than parent/guardian)
Last name_________________________ First name___________________ Relationship to student
Home phone
______________________
Work
______________________
Cell
_______________
______________________
EMERGENCY CONTACT 2 (other than parent/guardian)
Last name_________________________ First name________________ Relationship to student
Home phone
______________________
Work
______________________
Cell
_______________
______________________
**Please note when answering the questions below, the intent is if the language is spoken fluently as a home language.**
Is a language other than English spoken at home? Yes No If yes, what language_______________________________
Does the student speak a language other than English? Yes No If yes, what language___________________________
All of the above information is true and correct___________________________________________ ________________
Parent/Guardian Signature
Date
Community High School District #99
North High School
4436 Main Street · Downers Grove, IL 60515-2800
(630) 795-8400 · www.csd99.org
Parent/Guardian: Return this form to North High School
Sending school:
Send to:
School Name _______________________________
Ruth Schneider, Registrar
Street
_______________________________
Community High School District 99, North High School
_______________________________
4436 Main Street
City State Zip _______________________________
Downers Grove IL 60515
Phone
_______________________________
Phone 630-795-8425
Fax
_______________________________
Fax
630-795-8199
email [email protected]
______________________________________________________
Student Name

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



__________________________
Date of Birth
I give my permission to release any or all of the information listed below to North High School for the purpose of
enrollment, registration, and transfer of academic credit:
A sealed official transcript.
All medical and immunization records.
ISBE Student Transfer Form (Illinois schools only).
Grades in progress at time of withdrawal. (Please include date of withdrawal.)
Cumulative file and/or standardized test results.
Discipline records.
Special Education records, including current IEP and most recent case study evaluation.
_______________________________________________________
Signature of Parent/Guardian OR Student (if over 18 years of age)
_________________________
Date
According to the Family Educational Rights and Privacy Act, Final Rule on Educational Records, Federal Register, June 17,
1976, Vol. 41, No. 118, Page 24673, it is no longer necessary to obtain written consent to release records between schools. It
states that school officials within the educational institution and officials of other schools in the school systems in which the
student may intend to enroll, may receive a student’s records without written consent for such release.
Office Use Only for Sending School * Schools outside the state of Illinois and private schools *
Is this student currently under any suspension or expulsion from your district or private school?
 Yes  No
COMMUNITY HIGH SCHOOL DISTRICT #99
NEW STUDENT APPLICANT RESIDENCY AFFIDAVIT
Student Last Name_________________________________First Name___________________Middle_____________
Address______________________________________________City________________________Zip______________
Phone (______)___________________Lives with: Parent(s) Guardian
Parent(s)/Guardian(s) Name_________________________________________________________________________
Do you have legal custody of the student? Yes
No
Previous Address_______________________________________City_______________________Zip______________
Lived with________________________________________________________________Phone (_____)____________
Where did the student reside during the previous summer?_________________________________________________
Where did the student attend school last year?___________________________________________________________
Brothers & Sisters:
Name
Age Address
School Attending
_________________________ ____ _______________________________________ __________________________
_________________________ ____ _______________________________________ ___________________________
_________________________ ____ _______________________________________ ___________________________
Legal Residency Requirements
The right to attend a District #99 High School is extended to residents who live in the District Boundaries. Under the
law, the student’s residence is considered to be the home of his/her parent(s) or legal guardian(s). Students who
move into the school district to live with relatives or friends for the purpose of attending a District #99 High School are
not considered legal residents in the district and therefore cannot be admitted to the school. The District may
investigate the residence of any student before or after enrollment and require the involved persons to provide
additional information to be considered by the District in determining residency. Enrollment is not completed, and
attendance will usually not be permitted, until all residence issues are resolved.
ANY PERSON WHO KNOWINGLY ENROLLS OR ATTEMPTS TO ENROLL ON A TUITION-FREE BASIS A STUDENT WHOM THE
PERSON KNOWS TO BE A NON-RESIDENT, OR WILLFULLY PRESENTS FALSE INFORMATION REGARDING THE RESIDENCY OF
A PUPIL, SHALL BE GUILTY OF A CLASS C MISDEMEANOR, PUNISHABLE BY A FINE OF NOT MORE THAN $500 AND
IMPRISONMENT OF NOT MORE THAN 30 DAYS.
I certify that I am a legal resident of Community High School District #99. My signature below confirms all the
information provided and that the form is true and correct. I understand Illinois law has made it a crime to knowingly
and willfully present false information regarding residency of a student for purposes of enabling that student to attend a
District #99 high school when the student is known to be a non-resident of District #99. Parent/Guardian signature
below also gives permission to District #99 to contact individuals having knowledge of current residency, including but
not limited to landlords, lease holders, relatives where indicated, previous schools, etc.
_________________________________________________ _______________________________________________
Printed name of Parent/Guardian
Signature of Parent/Guardian
______________________________
Date
Community School District 99
NORTH HIGH SCHOOL
Special Needs History Information
** To be completed even if student does not have an IEP. **
Student’s Name
Former School
Has this student ever received Special Education services/support? Yes 
No 
When and what type of program?___________________________________________
Do you have copies of any IEPs? Yes 
No 
If yes, please provide a copy for the registrar. An IEP is required to initiate the enrollment process.
Has this student ever been accelerated or held back a grade? Yes 
No 
If yes, please explain:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Is there any significant information we should know regarding the student’s previous school experience? Yes
 No 
If yes, please explain:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Community School District 99 – North High School Health Services
4436 Main Street, Downers Grove, IL 60515
630-795-8480 phone 630-795-8399 fax
2015-2016 School Year
Dear Parent or Guardian,
The State of Illinois has revised the requirement for the Meningococcal vaccine of students entering
the 12th grade. The new requirement is: Beginning with the school year 2015-2016, any child
entering the 12th grade shall show proof of having received one dose of Meningococcal
conjugate vaccine on or after the age of 16 years.
Documentation of the Meningococcal vaccination, signed and dated by a health care provider, must
be provided to the nurse’s office of Downers Grove North High School prior to the first day of
attendance at school. Students will be excluded from attending class on the first day of attendance,
and every day thereafter, until documentation of the required vaccine has been received by Health
Services.
Please schedule an appointment with your child’s health care provider to receive this vaccine.
Depending on your insurance, you may also be able to receive the vaccine through the DuPage
County Health Department. You may schedule an appointment at the DuPage County Health
Department by calling 630-682-7400.
•
•
•
Senior transfers: Documentation of the Meningococcal vaccination, signed and dated by a
health care provider, must be provided to the nurse’s office of Downers Grove North High
School prior to the first day of attendance at North High School. Use the form below.
Out of State junior and senior transfer students: Have this vaccination given to your
student when you schedule your Illinois physical.
Students in 11th grade: This vaccination must be given after the age of 16 years and prior to
the first day of attendance as a senior for the school year 2016-2017.
Please note that a Meningococcal vaccination given before the age of 16 years will not be accepted.
If you have any questions, please contact your physician or the Health Office at 630-795-8480.
Meningococcal Vaccination
Student’s Name: __________________________________ Date of Birth: _____/_____/________
Date given: _________________
Health Care Provider’s Signature: _________________________________
Office Stamp is required with physician’s name, address and phone number.
DOWNERS GROVE NORTH HIGH SCHOOL
2015-2016 PHYSICAL EXAMINATION REQUIREMENTS
Health Services Phone: (630)795-8480/Fax: (630)795-8399
9TH GRADE/FRESHMAN REQUIREMENTS:
The School Code of Illinois requires that each student entering 9th grade have a physical examination on the
Illinois Certificate of Child Health Examination Form, completed by a licensed physician, an advanced practice
nurse, or physician’s assistant. A physical examination must include: height, weight, blood pressure, BMI,
diabetic screening, signatures and dates in order to be considered in compliance.
The Health History section on the back page of the Illinois Certificate of Child Health must be completed, signed
and dated by the parent/guardian of the child.
Student records must show proof of immunization series according to the guidelines of the Illinois Department
of Public Health; Diphtheria, Pertussis, Tetanus, Polio, Measles (Rubeola), Mumps, Rubella, Hepatitis B,
Varicella and Meningitis.
The State of Illinois does periodically update vaccination requirements for school age students. Any new
requirements will be communicated on the school website.
•
•
•
The physical examination must be submitted to the Health Services Office by August 1 of the current
school year. For transfers during the school year, see notes below for Transfer Students.
Students will not be eligible to receive a registration packet on Fee Payment Day unless all required
medical information has been submitted.
Freshman students will be excluded on the first day of school, and every day thereafter, until complete
immunization records, physical examination and parent/guardian health history have been received and
approved by Health Services.
Please retain a copy of the ninth grade physical with immunization dates for your records.
TRANSFER STUDENTS:
Students transferring from an Illinois school must present a copy of their ninth grade physical and a complete
immunization record at the time of registration.
Students transferring from another state or country MUST present prior current health records to the registrar
before any appointments will be scheduled, and an Illinois physical will be required within a specified time.
Students transferring to an Illinois public school for the first time are required to have a vision examination
conducted by a physician or licensed optometrist.
12TH GRADE/SENIOR REQUIREMENTS:
Beginning with the 2015/2016 school year, any child entering the 12th grade shall show proof of having
received two doses of meningococcal conjugate vaccine prior to entering the 12th grade. The first dose shall
have been received on or after the 11th birthday, and the second dose shall have been received on or after the
16th birthday, at least eight weeks after the first dose. If the first dose is administered when the child is 16
years of age or older, only one dose is required.
Students entering 12th grade will be excluded on the first day of school, and every day thereafter, until
documentation of the required meningococcal vaccination has been received and approved by Health
Services.
DOWNERS GROVE NORTH HIGH SCHOOL
2015-2016 PHYSICAL EXAMINATION REQUIREMENTS (continued)
ATHLETIC PARTICIPATION:
If your child will be participating in any of the Athletic programs, the physical examination must be completed
AFTER JUNE 15th to ensure participation for the full school year.
For freshmen only: the 9th grade physical on the State of Illinois form is valid for twelve months toward
athletic participation. The IHSA Sports Physical is not acceptable for 9th grade entrance. Only a physical
examination completed on the Illinois Certificate of Child Health Exam form is acceptable.
HEALTH CONCERNS:
If your child has specific health concerns, please note these concerns on the Certificate of Child Health
Examination form. Contact the school nurse at the beginning of the school year to coordinate care and plan
for potential emergency response. Update emergency contact information as needed throughout the
school year.
COMMUNICABLE DISEASE INFORMATION:
All information regarding a confirmed or suspected case of a communicable disease in the school population
will be reported to the DuPage County Health Department as mandated.
Students who are unimmunized or under-immunized to measles are considered susceptible to the disease. In
the event that a suspected or confirmed case of measles is reported in the school, and upon direction of the
DuPage County Health Department, students who are susceptible to measles will be excluded from school
until acceptable proof of immunity is received by the school or until 21 days from the onset of the last
reported measles case. Excluded students will not be permitted to participate in extracurricular or athletics
activities for the same period of time.
Outbreaks of other communicable diseases may also result in exclusion of susceptible students as determined
by local and state health departments.
MEDICATION POLICY:
Community High School District 99 acknowledges that the responsibility for administering medication to a
student rests primarily with the student’s parent or guardian. Medication will be administered by district
personnel during the school day only when absolutely necessary for the health and well-being of the student.
The initial dose of the medication must be given at home.
If medication is necessary, it must be brought to the school in the original container labeled by the pharmacist
(or manufacturer of over-the-counter medications). All medications, including over-the-counter medications,
must be accompanied by the district’s medication authorization form completed and signed by both the
parent and the physician; each medication must be on a separate form. Medication authorization forms are
available in Health Services or on the school website at www.csd99.org . It is important to note that students
are prohibited from carrying medications or keeping medications in their lockers. Only students authorized to
self-administer asthma medication or rescue epinephrine are permitted to carry medications on their person.
Questions or concerns regarding the above policies may be directed to the Health Services offices of North
High School (630-795-8480).
FOR USE IN DCFS LICENSED CHILD CARE FACILITIES
State of Illinois
Certificate of Child Health Examination
Student’s Name
Birth Date
Last
First
Address
Middle
Street
City
Sex
CFS 600
Rev 2/2013
Race/Ethnicity
School /Grade Level/ID#
Month/Day/Year
Parent/Guardian
Zip Code
Telephone # Home
Work
IMMUNIZATIONS: To be completed by health care provider. Note the mo/da/yr for every dose administered. The day and month is required if you cannot
determine if the vaccine was given after the minimum interval or age. If a specific vaccine is medically contraindicated, a separate written statement must be
attached explaining the medical reason for the contraindication.
1
MO DA YR
2
MO DA YR
TdapTdDT
TdapTdDT
 IPV  OPV
 IPV  OPV
Vaccine / Dose
3
MO DA YR
6
MO DA YR
4
MO DA YR
5
MO DA YR
TdapTdDT
TdapTdDT
TdapTdDT
TdapTdDT
 IPV  OPV
 IPV  OPV
 IPV  OPV
 IPV  OPV
DTP or DTaP
Tdap; Td or Pediatric
DT (Check specific type)
Polio (Check specific
type)
Hib Haemophilus
influenza type b
Hepatitis B (HB)
COMMENTS:
Varicella
(Chickenpox)
MMR Combined
Measles Mumps. Rubella
Measles
Single Antigen
Vaccines
Rubella
Mumps
Pneumococcal
Conjugate
Other/Specify
Meningococcal,
Hepatitis A, HPV,
Influenza
Health care provider (MD, DO, APN, PA, school health professional, health official) verifying above immunization history must sign below. If adding dates
to the above immunization history section, put your initials by date(s) and sign here.)
Signature
Title
Date
Signature
ALTERNATIVE PROOF OF IMMUNITY
Title
Date
1. Clinical diagnosis is acceptable if verified by physician.
*(All measles cases diagnosed on or after July 1, 2002, must be confirmed by laboratory evidence.)
*MEASLES (Rubeola) MO DA YR MUMPS MO DA YR VARICELLA MO DA YR
Physician’s Signature
2. History of varicella (chickenpox) disease is acceptable if verified by health care provider, school health professional or health official.
Person signing below is verifying that the parent/guardian’s description of varicella disease history is indicative of past infection and is accepting such history as documentation of disease.
Date of Disease
Signature
3. Laboratory confirmation (check one) Measles
Lab Results
Date
Title
Mumps
MO
DA
Date
Rubella
Hepatitis B
Varicella
(Attach copy of lab result)
YR
VISION AND HEARING SCREENING BY IDPH CERTIFIED SCREENING TECHNICIAN
Date
Code:
Age/
Grade
R
L
R
L
R
L
R
L
R
L
R
L
Vision
Hearing
IL444-4737 (R-02-13)
(COMPLETE BOTH SIDES)
R
L
R
L
R
L
P = Pass
F = Fail
U = Unable to test
R = Referred
G/C =
Glasses/Contacts
Printed by Authority of the State of Illinois
Sex
Birth Date
Last
First
HEALTH HISTORY
ALLERGIES (Food, drug, insect, other)
Middle
School
Grade Level/ ID
Month/Day/ Year
TO BE COMPLETED AND SIGNED BY PARENT/GUARDIAN AND VERIFIED BY HEALTH CARE PROVIDER
MEDICATION (List all prescribed or taken on a regular basis.)
Diagnosis of asthma?
Child wakes during night coughing?
Yes
Yes
No
No
Loss of function of one of paired
organs? (eye/ear/kidney/testicle)
Yes
No
Birth defects?
Yes
No
No
Yes
No
Hospitalizations?
When? What for?
Yes
Developmental delay?
Blood disorders? Hemophilia,
Sickle Cell, Other? Explain.
Diabetes?
Yes
No
Yes
No
Yes
No
Surgery? (List all.)
When? What for?
Serious injury or illness?
Yes
No
Head injury/Concussion/Passed out?
Yes
No
TB skin test positive (past/present)?
Yes*
Seizures? What are they like?
Yes
No
TB disease (past or present)?
Yes*
No *If yes, refer to local health
department.
No
Heart problem/Shortness of breath?
Yes
No
Tobacco use (type, frequency)?
Yes
No
Heart murmur/High blood pressure?
Yes
No
Alcohol/Drug use?
Yes
No
Family history of sudden death
before age 50? (Cause?)
Yes
No
Yes
No
Dizziness or chest pain with
exercise?
Eye/Vision problems?
Glasses  Contacts  Last exam by eye doctor
Other concerns? (crossed eye, drooping lids, squinting, difficulty reading)
Ear/Hearing problems?
Yes
No
Bone/Joint problem/injury/scoliosis?
Yes
 Bridge
 Plate Other
Information may be shared with appropriate personnel for health and educational purposes.
Parent/Guardian
No
PHYSICAL EXAMINATION REQUIREMENTS
 Braces
Dental
Signature
Date
Entire section below to be completed by MD/DO/APN/PA
HEAD CIRCUMFERENCE if < 2-3 years old
HEIGHT
WEIGHT
BMI
B/P
DIABETES SCREENING (NOT REQUIRED FOR DAY CARE) BMI>85% age/sex Yes No
And any two of the following: Family History Yes  No 
Ethnic Minority Yes No  Signs of Insulin Resistance (hypertension, dyslipidemia, polycystic ovarian syndrome, acanthosis nigricans) Yes No  At Risk Yes  No 
LEAD RISK QUESTIONNAIRE Required for children age 6 months through 6 years enrolled in licensed or public school operated day care, preschool, nursery school
and/or kindergarten. (Blood test required if resides in Chicago or high risk zip code.)
Questionnaire Administered ? Yes  No 
Blood Test Indicated? Yes  No 
Blood Test Date
Result
TB SKIN OR BLOOD TEST Recommended only for children in high-risk groups including children immunosuppressed due to HIV infection or other conditions, frequent travel to or born
in high prevalence countries or those exposed to adults in high-risk categories. See CDC guidelines.
No test needed 
Test performed 
Skin Test: Date Read
/ /
Result: Positive  Negative 
mm
Blood Test: Date Reported
/ /
Result: Positive  Negative 
Value
Date
LAB TESTS (Recommended)
Hemoglobin or Hematocrit
Urinalysis
SYSTEM REVIEW
Skin
Ears
Results
Date
Results
Sickle Cell (when indicated)
Developmental Screening Tool
Normal Comments/Follow-up/Needs
Normal Comments/Follow-up/Needs
Endocrine
Gastrointestinal
Eyes
Amblyopia Yes
Neurological
Throat
Musculoskeletal
Mouth/Dental
Spinal Exam
Cardiovascular/HTN
Nutritional status
 Diagnosis of Asthma
Respiratory
LMP
Genito-Urinary
No
Nose
Mental Health
Currently Prescribed Asthma Medication:
 Quick-relief medication (e.g. Short Acting Beta Agonist)
 Controller medication (e.g. inhaled corticosteroid)
NEEDS/MODIFICATIONS required in the school setting
Other
DIETARY Needs/Restrictions
SPECIAL INSTRUCTIONS/DEVICES e.g. safety glasses, glass eye, chest protector for arrhythmia, pacemaker, prosthetic device, dental bridge, false teeth, athletic support/cup
MENTAL HEALTH/OTHER Is there anything else the school should know about this student?
If you would like to discuss this student’s health with school or school health personnel, check title:
 Nurse
 Teacher
 Counselor
 Principal
EMERGENCY ACTION needed while at school due to child’s health condition (e.g. ,seizures, asthma, insect sting, food, peanut allergy, bleeding problem, diabetes, heart problem)?
Yes  No  If yes, please describe.
On the basis of the examination on this day, I approve this child’s participation in
PHYSICAL EDUCATION
Print Name
Address
Yes 
No 
Modified 
(If No or Modified please attach explanation.)
INTERSCHOLASTIC SPORTS
(MD,DO, APN, PA)
Signature
Phone
(Complete Both Sides)
Yes 
No 
Date
Limited 
Community High School District #99
North High School
4436 Main Street · Downers Grove, IL 60515-2800
(630) 795-8400 · www.csd99.org
Student Transfer Form
Statement of Student in Good Standing
If transferring from an Out-of-State or Private School Only
Student Name __________________________________________ Grade _________
Previous School ________________________________________________________
City and State __________________________________________________________
We hereby attest that this student left the previous school in good standing. The student has not been
expelled and is not currently serving a suspension from the previous school.
Signatures:
______________________________________________
Parent/Guardian
______________________________________________
Student
______________________________________________
Date