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San Bernardino City Unified School District

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Health Services Forms

Blank Action Plan Forms:

Allergy Action Plan
Asthma Action Plan
Seizure Action Plan
Migraine Action Plan


Forms requesting accommodations/services:

Medication Administration-Parent Letter
Medication Request form in English
Medication Request Form in Spanish 
Medical Statement Special Meals & Accommodations
Medical Statement Special Meals & Accommodations (Spanish)
Modified Physical Education
First Grade Physical Form (English and Spanish)
Oral Dental Form (English)
Oral Dental Form (Spanish)

777 North F Street, San Bernardino, CA 92410 | Phone: (909) 381-1100 | Fax: