I request school personnel to give my child, , the medication

I request school personnel to give my child, , the medication

Viola Cobb Elementary
Every Cobb Cougar Can Conquer Learning
Principal
Assistant Principal
Blake Smith
William Chalfant
I request school personnel to give my child, _______________________________________, the
medication provided by _________________________________________ for the period from
_____________________ to ____________________ (no longer than ten calendar days).
(Date)
(Date)
Por medio de la presente, doy mi consentimiento al personal de la escuela para dar a mi hijo(a),
_________________________________________________, el medicamento proveído por
__________________________________ durante el period de
______________ hasta________________ (no mas de diez días).
(fecha)
(fecha)
Name of medication: _________________________________________________
(Nombre de medicina)
Dosage to be given: __________________________________________________
(Dosis)
Time to be given: ____________________________________________________
(Hora de tomarla)
Allergies to drugs: ___________________________________________________
(Alergias)
Homeroom teacher: __________________________________________________
(Nombre del maestro)
Parent Signature: ______________________________________________
(Firma: padre o tutor)
Phone #: _____________________________________________________
(Telefono)
Date: ________________________________________________________
(Fecha)
________________________________________________________________
915 Dell Dale * Channelview, Texas 77530 * Off: 281-452-7788 * Fax: 281-452-7413