- Forms
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Home/Hospital School
Referral Forms: Home Medical Referral
Non-Medical Referral for Home Instruction
Medication
Request for Medication to be Taken During School Hours, Form 33.199 (Feb 2023)
Asthma Action Plan English/Spanish Jan 2024
Request for Self-Admin of Medication, From 33.205 (March 2023)
Request to Self-Carry Emergency Medication (English)
Request to Self-Carry Emergency Medication (Spanish)
Permanent Health History
Release of Medical Information
Authorization to Receive/Release Medical Information
Special Diet
Medical Statement to Request for Special Diet
- Immunization and Other Information
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In-Home COVID Vaccine for Homebound LA County Residents
Please contact 211 for assistance with basic needs and other resources at https://211la.org/search-resources
- Health Brochures
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Health Brochures
My Child Has A Health Problem
My Child Needs Medication
in School 
My Child Needs Medical Treatments During
the School Day 
My Child Has Severe Allergies
My Child Has Asthma
My Child Has Diabetes
My Child Has Seizures
- Specialized Physical Health Care Services (SPHCS) Authorization Forms
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Quick Links
