Linking Clinic & Community Interest Inquiry
The Kindness Campaign has partnered with a local healthcare system to have a mobile health unit (MHU) serve uninsured and underinsured Pre-K - 12 grade students. Service include School Physicals, Sports Physicals, Daycare Physicals, Immunizations and Well-Being Checks and Health Education.
Parent/Guardian Name
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First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
PLEASE LET US KNOW ABOUT YOU!
Are you the parent/guardian for a Pre-K - 12th grade student?
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Yes
No
How many students need service?
0
1
2
3
4
5
5+
Which service does the student(s) need? (Check All That Apply)
K - 8 School Physical
Sports Physical
Daycare Physical
Immunization
Well-being Check
Health Education
Is the student(s) enrolled in a school in the state of Illinois?
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Yes
No
Is the student(s) currently covered by government sponsored health insurance such as Medicaid, Medicare or The Marketplace (Obamacare)?
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Yes
No
How would you like to submit the application?
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I would like for the application to be emailed to me so I can print the application, complete and email the completed application to The Kindness Campaign
I would like to make an appointment to come to The Kindness Campaign 703 E 75th St Chicago, IL 60619 to have the application printed and to submit the completed application
Please use this section to ask any question or share any information (optional).
Signature
*
Today's Date
*
-
Month
-
Day
Year
Date
Submit
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