Guidelines for Completion of Health Registration Records

(The School Code of Illinois provides for exclusion from school for students not in compliance with health requirements.)

GUIDELINES for completion of the "Certificate of Child Health Examination"

  1. Freshman health records must be turned in to the Health Office by the first day of the school year. Transfer students must submit health records within 30 days of the registration.
  2. Information, including the student's name, should be entered on both sides of the 2-sided state form, "Certificate of Child Health Examination".
  3. The exam must be no earlier than one year prior to the first day of attendance at Belleville West and Belleville East. The exam form must be signed and dated by the examining physician (MD or DO), advanced practice nurse (APN) or physician's assistant (PA).
  4. All immunization dates must be recorded (month/day/year) and the section must be signed by a physician or other health care provider. If an immunization is medically contraindicated, a statement must be written by the MD, DO, APN or PA and attached to the student's physical exam form. Please note that two doses of measles vaccine and three doses of hepatitis B are required. Also, if ten years have elapsed since the last tetanus booster, an additional booster is required. The St. Clair County Health Department offers immunizations at a reduced cost during weekly clinics (618.233.6170).
  5. Approval to participate in Physical Education and Interscholastic sports (near the bottom of the page) must be checked by the examining physician, advanced practice nurse, or physician's assistant. Modifications, if indicated, must be specified.
  6. The Health History section (half page) must be completed and signed by a parent or legal guardian.
  7. Arrange for an appointment with your physician or clinic now or as soon as possible. Physical examination schedules fill quickly during the summer months. Make a copy of the health records for your home file and return the forms by mail as soon as they are completed.

GUIDELINES for completion of other Health Records:

  1. Please complete an emergency information card. The information requested allows us to contact alternate adults in case of student illness or injury when a parent or guardian is unavailable. Parents and legal guardians have the responsibility to provide updated health and contact information as changes occur during the student's enrollment.
  2. If your child has a special health need, please contact the School Nurse to discuss his/her condition prior to the start of the school year. Medical information concerning a safe school routine can then be efficiently passed on to teachers.
  3. If your student requires any prescription or nonprescription medication (including Tylenol and ibuprofen) during school hours, please complete a Medication Authorization Form annually.
  4. Athletic Physicals: Students must have an annual physical exam on file prior to participating in any sports program. The ninth grade physical exam (on file in Health Services) qualifies as a sports physical for freshman students; however, a sports physical does not qualify as a freshman physical. Health Services notifies the Athletic Office of all freshman physicals on file. Athletic physicals for all other students (non-freshman) need to be submitted to the Health Office. Students are encouraged to arrange their physical exam date to assure sports eligibility throughout their athletic season.

Certificate of Child Health Examination (physical form)






Health Records Info and Release for Transfer Students

Belleville Township High School District 201
920 N. Illinois St.
Belleville, IL 62220


Students transferring from an Illinois school as an incoming freshman (9th grade) must have a physical examination and up-to-date immunization record within 30 days of the registration date.

Students transferring from an Illinois school as an incoming 10th, 11th or 12th grader should have a ninth grade (or more recent) physical examination and immunization record from the transferring Illinois school.

Students transferring from out-of-state or out-of-country must have a physical examination and up-to-date immunizations, along with a vision exam, within 30 days of the registration date.

NOTE: Students who fail to have a completed physical examination and up-to-date immunization records on file with the Belleville West and East school nurses within 30 days of registration, will be excluded from school until these requirements are met. If you have any questions, call Health Services at 222.7649 for Weat and 222-3735 for East.

Certificate of Child Health Examination (physical form)

Return to Health Services

Student Name________________________________________________________________Grade_________________



Name of school holding records________________________________________________________________________

School Address_____________________________________________________________________________________

City, State, Zip _____________________________________________________________________________________

School Phone ______________________________________________________________________________________

1) I hereby authorize the Registrar or nurse at the aforementioned school to release my child's health
records to Health Services at Belleville Township High School.

2) I further give my permission for my child to participate in all physical education activities.

Parent/Guardian Signature_______________________________________________________Date________________


Medication Authorization Forms

Medication Authorization Forms

If a student requires any prescription or nonprescription medication, including Tylenol and ibuprofen, during the school day, a Medication Authorization Form must be completed by both the attending physician and the parent or guardian. These forms must be completed annually.

Prescription medication brought to school must be in a current pharmacy labeled container. Non-prescription or over-the-counter medication must be in the manufacturer's original package and labeled with the student's name.

Non-Prescription Medication Self-Administration Form

Authorization and Permission for Administration of Prescription Medication Form