School Supplies Form ENG

Value Added Service | School Supplies

*Valid September 1, 2026 to August 31, 2027
Dear Cook Children’s Health Plan Member,

Cook Children’s Health Plan would like to send you a $50 reward for school supplies when Member completes required:
• Meningococcal Immunization
• TDAP Immunization
• HPV Immunizations

For ages 9-13 and enrolled with Cook Children's Health Plan for a minimum of 6 months.

*Date of service must be within the current fiscal year (September 1, 2026 - August 31, 2027)
Member name:
(first and last name)
Member ID number:
Member DOB:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Name of Provider:
(first and last name)
Meningococcal vaccine:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate of vaccination:
TDAP vaccine:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate of vaccination:
HPV Vaccine 1st dose:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate of vaccination:
HPV Vaccine 2nd dose:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate of vaccination:
Please remember to register or log in to Healthmine to access your digital gift card and rewards.

Some limitations and restrictions may apply. Member must be active both on the date of service and on the date of request. If you have any questions please visit our website www.cookchp.org, contact us through the MyCookChildren’s Member Portal or call Member Services at 1-800-964-2247.
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