State of Illinois 
Department of Public Health 
EYE EXAMINATION WAIVER FORM 
Please print: 

Student's Name: Last First Middle Birth Date: (Month/Day/Year) 
Address: Street City ZIP Code Telephone: 
Name of School: Grade Level: Gender: 
Male Female 
Parent or Guardian: Address (of parent/guardian): 

I am unable to obtain the required eye 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. 
• 
My child does not have any type of medical or vision/eye care coverage, my child does not 
qualify for medical assistance/ALL KIDS, there are no low-cost vision/eye clinics in our 
community that will see my child, and I have exhausted all other means and do not have 
sufficient income to provide my child with an eye examination. 
• 
Other undue burden or a lack of access to an optometrist or a physician who provides eye 
examinations: 
Signature Date 
(Source: Added at 33 Ill. Reg. ______, effective ____________)