Student Health Form

1.	Student ID#*

2.	Student First Name*

3.	Student Last Name*

4.	Grade*

5.	Name of Person the person completing the medical information update.*

6.	List any allergies the student has.

7.	List any special conditions the student has.

8.	I give permission for my child to be administered the following over the counter medications provided by the school.
	Cough Drops    Ibuprofen (Advil, Motrin)    Acetaminophen (Tylenol)    Antacid (Tums)    Diphenhydramine HCL (Benadryl)    Ambesol    Sore Throat Spray    Sunscreen    Insect Repellant    Other, please specify

9.	Physician Information
	Doctor's Name   Doctor's Phone Number

10.	Dental Information
	Dentist's Name   Dentist's Phone Number