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Health Records Info and Release for Transfer Students

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

HEALTH RECORDS INFORMATION and RELEASE
FOR TRANSFER STUDENTS

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)


HEALTH RECORDS and PHYSICAL EDUCATION RELEASE
Return to Health Services

Student Name________________________________________________________________Grade_________________

Address_______________________________________________________________________Phone_______________

City,State,Zip_______________________________________________________________________________________

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________________