Health Exam forms are due by August 10, 2021

Per School Board Policy 7:100, students not meeting the physical examination and immunization requirements prior to the first day of school will not be allowed to start classes.

  1.  PHYSICAL EXAMINATION
  • Completed within one year of entry into Kindergarten and on the Department of Human Services (DHS) examination form.
  • Health History portion at the top of the form must be completed, signed and dated by parent/guardian.
  • Incomplete examination forms will not be accepted and will be returned.
  • Keep a copy for your records.
  1.   IMMUNIZATIONS:  All as required by the Illinois Department of Public Health  including the following:
  •  Poliomyelitis:  Four or more doses at the appropriate intervals with the last dose received on or after the 4th   birthday and 6 months or more since the last dose.
  •  Diphtheria, Tetanus, Pertussis (DTaP or DTP):  Four or more doses at the appropriate intervals, with the last dose being received on or after the 4th birthday.
  •  Measles, Mumps, Rubella (MMR):  Two doses of MMR Vaccine, the first being on or after 12 months of age and the second dose no less than 1 month after the first.
  •  Varicella (chicken pox): Two doses on or after 12 months of age or older and the second dose no less than 1 month after the first or verified history of the disease.               
  1.  DENTAL EXAMINATION 
  • Due by May 15th of the 21-22 school year 
  1. EYE EXAMINATION
  • Due by October 15th of the 21-22 school year

               Parents/guardians who object to examination(s) or immunizations(s) on religious grounds must complete and submit the Illinois Certificate of Religious Exemption form.  This form must be completed in its entirety by the parent/guardian and signed by the physician, advanced practice nurse or physician assistant performing the examination.  The statement must set forth the specific religious belief that conflicts with the examination(s) and/or immunizations(s).  Each vaccine that is objected, must be listed.  The form is available on the Public Health website at www.dph.illinois.gov – search “religious exemption” or on the D300 website under “Health Services”.

Specific Health Forms:  If applicable, the following forms need to be completed and signed by your physician each year:

  • Medication Authorization request forms
  • Allergy Action Plans
  • Asthma Action Plans
  • Diabetes Medical plans
  • Seizure Action Plans

These forms can be found on the District website under “Health Services” or they are available from any D300 Health Office.

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Contact Info
Peoria Hebrew Day School
  • 5614 N University St
  • 309.692.2821
  • peoriadayschool@sbcglobal.net

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