Health Office » Health Forms

Health Forms

Welcome to the Health Office for John Marshall High School
Please note that there is a Health Center on campus that runs independently by Asian Pacific Health Care Venture, Inc. (APHCV), a nonprofit community health center. Visit their webpage on this school website by choosing “Parents,” then “Health Center.”
For Immunization Information, please click on the Side Link “Immunization Info” .
Para obtener información sobre inmunizaciones, haga clic en el enlace lateral " Info de Vacunación".
Please scroll down for common Forms needed for Medications, Sports Health Clearances, and Return to School with an Injury.
For more information & additional forms, click on the LAUSD Nursing’s Parent Resources Link or Google “LAUSD Parent Resources Nursing”: LAUSD Nursing Parent Resources


California Education Code Section 49423.
  • Students may not carry or use medication on campus without written consent.
  • Written authorizations must be signed by the licensed health care provider and by the parent/guardian.
  • *The medication authorization requires annual renewal and is valid one calendar year from the date of the licensed health care provider’s signature.

For Asthma medications: (example: Albuterol)

For Asthma Diagnosis where Albuterol is prescribed: *If you have a respiratory diagnosis that is other than “Asthma” (e.g. SOB Shortness of Breath, RAD Reactive Airway Disease, EIB Exercise Induced Bronchospasm), you can use the “Self-Administration Medication” Forms.
If your child cannot give your inhaler to themselves, then use the “Request for Medication to be Taken at School.”
For Epinephrine medications: (examples: EpiPen, Auvi-Q, Adrenaclick)
The "Emergency Treatment for Anaphylaxis: Epinephrine Auto Injector" form and The Self Administration Medication Form (if the Pen is to be possibly self-injected) is signed by the Healthcare Provider and Parent. #1-7 is completely filled out.
For Self-Administration (self-carry) Medications: *If you use an inhaler for Asthma, use the Asthma
Action Plan form above.
This medication form authorizes the Student to self-carry and self-administer medication during school hours, during field trips, and athletic events. For Controlled Substances, please use form in next section below - "Request for Medication to be Taken During School Hours".
For Medications that must be stored in Health Office and given by Trained Staff. (Examples include Substance 2 Stimulants such as Amphetamine (Adderall ®), methylphenidate (Ritalin®). This medication form authorizes Staff to administer medication to the Student during school hours, during field trips, and athletic events.
ADMINISTRATIVE GUIDE 2312-6: Children wearing braces, casts or using crutches, wheel chairs, and the like, shall be permitted to attend school only on written permission of the physician in charge of the case.


Please email the School Nurse (sidebar link on "Health Office" page) for a helpful form that the Healthcare Provider (HCP) can fill out. Or Alternatively, an acceptable medical note from your HCP will have the following:
  • Student’s Name, Birthdate.
  • Medical reason for the accommodation/limitation.
  • Description of the accommodation/limitation.
  • Duration of this accommodation/limitation.
  • HCP’s Signature & Legible Name, Credentials, and Sign Date.
(Please note that all medical notes are valid for 1 calendar from HCP’s sign date and will need to be renewed.)

ATHLETICS. LAUSD Sports Physical Forms

The Sports Evaluation requires annual renewal and is valid one calendar year from the date of the licensed health care provider’s signature.
Written authorizations must be:
  • signed by the licensed health care provider
  • signed by the parent/guardian and
  • have a clinic ink stamp
  • explain ALL “Yes” answers to help process your form. Please use black or blue ink, not pencil, to fill out the form.
  • have passing eye vision results (20/30 or better in each eye). Bring your corrective lenses for the physical.
NEW Forms:

ATHLETICS. IF COVID 19 Positive Test History. Please Download & the Entire Letter.

Dear LAUSD athletes and their parents/guardians:
COVID-19 and its wide range of complications may present challenges to everyday activities. One of the complications affecting sports participation is damage to the heart. The greater the severity of COVID-19, the greater the risk is for heart disease. Please speak to your health care provider regarding sports participation after a positive test for COVID-19 within the last 3-6 months or if at any time you have symptoms consistent with COVID-19 (fever/chills, cough, shortness of breath or difficulty breathing, muscle or body aches, headache, new lost sense of taste or smell, sore throat, nasal congestion, nausea, vomiting, and/or diarrhea). Your health care provider should include screening questions for cardiac symptoms such as palpitations, irregular pulse, chest pain, difficulty breathing, fainting, and fatigue, and complete the medical clearance form, “COVID-19 Return to School and Clearance to Begin COVID Graduated Return to Play (GRTP).” See Form next section.
ATHLETICS. COVID 19 Return to School & Clearance to Begin COVID Graduated Return to Play GRTP 
READ Sports Letter to Parent/Guardian/Athlete Letter FIRST to determine if you need the Medical Clearance Form and/or GRTP.
Must be completed by a Healthcare Provider (MD/DO/NP/PA). Must be Ink Stamped.
If you tested Positive + for COVID-19 (Answered "YES" to PPE Question #9), you MUST submit the COVID Medical Clearance Form: NEW April 27, 2021 COVID-19 Medical Clearance Form

ATHLETICS. Concussion Injuries

Concussion Injury Report Form (usually filled out by Supervising Coach and evaluating MD/DO) -- Parents, please review and sign form before returning to School Nurse upon return to school.
Concussion Medical Clearance Form is Needed to start Stage III of RTP Protocol (signed by MD/DO):
For more information & additional forms, click on the LAUSD Nursing’s Parent Resources Link or Google “LAUSD Parent Resources  Nursing”: