Advocate Christ Medical Center
i am...
a patient or visitor a physician or health care professional an employer

By filling out this form, I approve that my (our) daughter/son (as typed below), has my (our) consent to serve as a teen volunteer at Advocate Christ Medical Center.

I (we) have read the application/agreement and will share in the responsibility of this commitment.

I (we) also give my (our) consent for my (our) daughter/son to receive necessary TB (Mantoux) testing and the Influenza Vaccination.

PLEASE CALL EMPLOYEE HEALTH 708.684.5333 FOR ANY QUESTIONS OR CONCERNS.

NOTE: A COPY OF MMR AND VARICELLA IMMUNIZATIONS MUST BE PRESENTED AT TIME OF TB.
* Indicates required information
Parent/Guardian Name * 
Email Address * 
Daughter/Son's name * 
Authentication * 

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