McLean County, IL · McLean County
Child Health Clinic Permission/Proxy Form
Parents or legal guardians use this form to authorize an adult proxy to bring their child to specified McLean County Health Department clinics and consent to treatment.
At a glance
- Issued by
- City of McLean County · McLean County, McLean County, Illinois
- Notarization
- Not required: file this form without a notary.
- Official source
- mcleancountyil.gov
- Blank form
- Download the PDF
- Catalogued
- Machine-readable
- JSON record · about the forms index
What this form is
This form lets a parent or legal guardian designate an adult, age 18 or older, to bring their child to immunization, dental, or TB clinic appointments, stay during treatment, and consent to treatment. The parent or guardian and designated proxy must sign it before the child's appointment. It asks for the child's name and birth date, proxy details, and signatures; step-parents must be designated unless legal guardianship documentation exists.
Who needs it
A parent or legal guardian who wants an adult other than themselves to bring their child to a listed clinic and consent to treatment needs this form.
How to submit it
Return the form to McLean County Health Department, 200 W. Front St., Room 104, Bloomington, IL 61701.
About notarization
This form is signed without a notary; the parent or guardian and designated proxy sign it, and the parent or guardian dates it.
How to submit this form
- 1
Download the Form
Download the McLean County Health Department Permission/Proxy Form.
- 2
Complete the Form
Enter the child's name and birth date, identify the proxy, and have the parent or guardian and designated proxy sign before the appointment.
- 3
Check for Attachments
The form does not list an attachment to gather. Step-parents must be designated unless legal guardianship documentation exists.
- 4
Return the Form
Return it to McLean County Health Department, 200 W. Front St., Room 104, Bloomington, IL 61701.
Frequently asked questions
- Do I need a notary for the Child Health Clinic Permission/Proxy Form?
- No. The form is signed without a notary; the parent or guardian and designated proxy sign it, and the parent or guardian dates it.
- Who can be designated as a proxy?
- The form allows you to designate a person other than yourself who is at least 18 years old. Step-parents must be designated unless legal guardianship documentation exists.
- How do I submit the Permission/Proxy Form?
- Return it to McLean County Health Department, 200 W. Front St., Room 104, Bloomington, IL 61701.