State of Illinois

Illinois Department of Public Health

Eye Examination Waiver Form

Please print:

Student Name _____________________________________________________________ Birth Date ______________

(Last) (First) (Middle Initial) (Month/Day/Year)

School Name __________________________________________ Grade Level________ Gender: Male Female

Address __________________________________________________________________________________________

(Number) (Street) (City) (ZIP Code)

Phone___________________________

(Area Code)

Parent or Guardian _________________________________________________________________________________

(Last) (First)

Address of Parent or Guardian ________________________________________________________________________

(Number) (Street) (City) (ZIP Code)

I am unable to obtain the required vision examination because:

 My child is enrolled in medical assistance/ALL KIDS, but we are unable to find a medical doctor who performs eye

examinations or an optometrist in the community who is able to examine my child and accepts medical assistance/

ALL KIDS.