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Student Health Services Health Forms, Documents, Information

Health Forms

Authorization for medication administration:
This form is required for any medication, over the counter or prescription.

Medication authorization form 2019-20 School Year (Click here)
This form is needed for any type of medication whether it is prescription or over the counter.

This form must be signed by a physician and must be renewed each school year. A doctor of chiropractor is NOT acceptable.

Diabetes medical management plan:
Regardless of a student’s independence with their Diabetes, students will still need written orders on file in the health office in case of an emergency. The orders must also include an order for Glucagon.

Diabetes Medical Management Plan (PDF)

DIASTAT authorization forms:  English (PDF)| Spanish (PDF)

G TUBE feeding physician orders: (PDF)

Specialized health care services (parent request):
This form is used for two purposes. The first purpose is for students that are in our Special Education classes and who require assistance with activities of daily living.  The second purpose is for students that are not enrolled in special education however, need assistance with anything on an ongoing basis that does not otherwise have its own form.  Examples include: scoliosis braces or bathroom assistance during a broken appendage. A new form is completed each year.  English & Spanish (PDF)

Specialized health care services (physician order/request):
This form may accompany the above form if the service requires a physician’s order. If you are not sure whether or not you need a physician’s order, please contact the nurse at your child’s school.  (PDF)

Release of Information:
This form is needed when a member of the school will need to contact the physician for many different reasons. A couple of reasons include: correcting errors within physician’s orders in a timely manner or discussing certain procedures that are unclear in physician’s orders. This is very helpful for nurses when parents are having difficulty contacting their child’s provider.

English (PDF)| Spanish (PDF)

Request for PE modification due to injury or illness:
This form is for students that have sustained an injury or have an illness and will need to be out of PE for a prolonged period of time. This form is recommended for a child that has broken his leg and will be in a cast for over 5 days or someone that is still in recovery from a surgery. This form is not be used for PE exemptions. PE exemptions are school board approved, case-by-case applications for students that have no ability to perform PE including an adaptive PE class. This process begins with your student’s counselor. Please contact them for further information.  (PDF)

Student Health history:This form is used for student’s that need to complete a recent health history for a triennial IEP or if the student has had a change in their health condtion. English (PDF)| Spanish (PDF)

Vagus Nerve Stimulation authorization forms: English (PDF)| Spanish (PDF)

Medical management form (Click here)
This is a generalized form and is used for any condition that we do not have a form already created for. Meaning, conditions other than: seizures, asthma, G tube feeding, or bee allergies. Examples of children who may need a medical management form: migraines, heart conditions, menstrual cramps, anxiety, fainting, high blood pressure. These forms may also be used in combination with someone that requires a special medication and further guidance for the health staff would be helpful.

If your child has a condition, please have the provider complete this form.

If your child does not have a health condition, and you received this form, please write” my child does not have a current health condition that requires attention while at school” and sign/date.

Medication authorization form 2019-20 School Year (Click here)
This form is needed for any type of medication whether it is prescription or over the counter.

This form must be signed by a physician and must be renewed each school year. A doctor of chiropractor is NOT acceptable.

Asthma form
This form is needed to better manage the symptoms of an attack.

This form must be completed by a physician. This form should be updated each year or when your child’s asthma care changes.

Bee information letter English | Bee information letter Spanish
This form should be completed to give a history of your child’s reaction, if any, to a bee sting. This is for health office staff to understand what reactions your child has had in the past and to be prepared for an emergency situation.

Statement child does not have asthma
This form is used for children that have been cleared as not having asthma by a medical doctor. This form does not need to be signed by a physician, however it is recommended to have a medical doctor sign and confirm.

Statement child does not have a certain/previously noted health condition
This form is used for children that may have had a condition at birth and no longer need a care plan by being cleared from a physician. Example of some conditions may include minor heart conditions, febrile seizures, accommodations for a broken appendage, or an allergy. If your child has not been cleared by a physician, we do not recommend that you complete this form. However, during the next annual physical examination for your child, it is encouraged that you ask about the condition and if they will continue to need a classroom healthcare plan. It is best to have the condition listed for the health team than to not have it included. During an emergency, paramedics are given their health history and it is highly recommended that we have the most up to date information. Example, we could update the record by stating, “history of asthma” instead of “asthma”.

If you do not see a form listed here or in the forms section, please email Callie Escobedo: cescobedo@euhsd.org to obtain the correct form.

For additional forms click here: English or Spanish

Communicable Diseases

Pertusis (PDF): English (PDF)| Spanish (PDF)

Bed Bugs: English (PDF)| Spanish (PDF)

Chicken Pox: English (PDF)| Spanish (PDF)

CMV: English (PDF)| Spanish (PDF)

Emergency First Aid Guidelines (PDF)

Exclusion Policies School Control Measures (PDF)

Facts About Fifth Disease: English (PDF)| Spanish (PDF)

Hand, Foot Mouth Disease: English (PDF)| Spanish (PDF)

Impetigo: English (PDF)| Spanish (PDF)

Mono: English (PDF) Spanish (PDF)

Pinworms: English (PDF)| Spanish (PDF)

Scabiles: English (PDF)| Spanish (PDF)

Streptococcus Scarlet Fever: English (PDF)| Spanish (PDF)

Zika: The Basics of the Virus and How to Protect Against It (cdc.gov)

Measles: The basics English (PDF) | Spanish (PDF)

Information regarding California health care for all children:

All In: Health Care for All Families

IMM-231 California Immunization Requirements Changes effective beginning in the 2019-20 school year.

Influenza-like Illness

Parent’s Guide to MRSA

What is Enterovirus D68?

Info for Students

All In: Health Care for All Families

IMM-231 California Immunization Requirements Changes effective beginning in the 2019-20 school year.

Influenza-like Illnesses

Neighborhood Health Care: Services and presentations on pregnancy prevention, preventive healthcare, medical screenings, HIV/STD education and prevention, guide to healthy relationships, and abstinence.

Preventing Youth Suicide

School Health Services Team

District Nurse
Credentialed School Nurse

Callie Escobedo RN MSN PHN
Phone: (760) 291-3007
cescobedo@euhsd.org
Fax: (760) 741-1846

  • START Program
  • IEP Health Reports
  • 504
  • Staff Training (Medical team participant procedures & conditions)
  • Medical Procedure Compliance
  • IHP (Classroom health care plans)
  • Guidance for home hospital resource

School Health Services Staff

Escondido High School

Lisa Courduff LVN
Student Health Specialist
Phone: (760) 291-4080
lcourduff@euhsd.org
Fax: (760) 741-1935

Health Office Clerk
Marissa Glaser
Phone: (760) 291-4081
mglaser@euhsd.org


Orange Glen High School

Leticia Gonzalez LVN
Student Health Specialist
Phone: (760) 291-5080
letgonzalez@euhsd.org
Fax: (760) 839-9270

Cynthia Martinez
Health Office Clerk
Phone: (760) 291-5081
cmartin@euhsd.org


San Pasqual High School

Caroline Akers, RN
Student Health Specialist
Phone: (760) 291-6080
cakers@euhsd.org
Fax: (760) 745-1834

Health Office Clerk
Joey Lee

Phone: (760) 291-6081
jlee1@euhsd.org


Del Lago Academy

Marylou Villasenor RN
Student Health Specialist
Phone: (760) 291-2581
Fax: (760) 746-0453
mvillasenor@euhsd.org


Valley High School

Mon & Wed 8 – 12 pm
Phone: x2253