Health Forms

Medication Forms

Each school year, written authorization from a health care provider licensed in the State of California is required for students needing assistance with prescription and/or over-the counter medications during school. (Ed. Code 49423)

Please contact your school nurse with any questions.

1) ABC Request for Assistance with Medication (English) 4544-HS 03.06
2) ABC Request for Assistance with Medication (Spanish) 4544- HS 03.16.17
3) Anaphylaxis Medication - Physician Authorization 04.11
4) Anaphylaxis Medication Self Carry - Physician Authorization 04.11
5) Asthma Medication - Physician Authorization 04.11
6) Asthma Medication Self Carry - Physician Authorization 04.11
7) American Diabetic Association Diabetic Plan 12.16.21

Seizure Forms

8) Seizure - Physician Authorization Anti-Seizure Medication 01.13
9) Seizure - Physician Authorization Vagus Nerve Stimulator 01.13
10) Seizure - Physician Authorization Post Seizure Protocol 01.13
11) Seizure - Parent Request Emergency Medication 12.12
12) Seizure Action Plan - Epilepsy Foundation (English) 01/20
13) Seizure Action Plan - Epilepsy Foundation (Spanish) 01/20

School Entry Forms (English)

14) CDPH Immunization Parent Guide (English) 12.2022
15) DHCS Health Exam for School Entry (English) 09.2007
16) CDE Oral Health Assessment (English) 4672-HS 05.29.20
17) ABC Health & Developmental History K-12 (English) 4500-HS 03.01.21

School Entry Forms (Spanish)

18) CDPH Immunization Parent Guide (Spanish) 12.2022
19) DHCS Health Exam for School Entry (Spanish) 09.2007
20) CDE Oral Health Assessment (Spanish) 4672-HS 05.29.20
21) ABC Health & Development History K-12 (Spanish) 4500-HS 03.01.21

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MD recommended School Participation after injury (Recovered)