GUARDIAN PERMISSION FOR NON

I request and authorize school personnel from the Delavan-Darien School District to administer medication to the above named student. Name of medication: ...
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PARENT/GUARDIAN PERMISSION FOR NON-PRESCRIPTION MEDICATION

Name of Student _____________________________________________ Birthdate ________________________ School ________________________________________ Grade/Teacher_________________________________

Dear Parent/Guardian: I request and authorize school personnel from the Delavan-Darien School District to administer medication to the above named student. Name of medication:_______________________________________________________________________ Dosage: ________________________________________________________________________________ Time to be given:________________________________________________________________________

Parent/Guardian signature ________________________________________________ Date _________________

PERMISO DE LOS PADRES/TUTORES PARA ADMINISTRAR MEDICAMENTOS QUE NO REQUIEREN PRESCRIPCIÓN MÉDICA

Nombre del Estudiante _____________________________________ Fecha de Nacimiento _________________ Escuela ____________________________________ Grado/Maestro/a_________________________________

Estimados Padres/Tutores: Yo solicito y autorizo al personal escolar del Distrito Escolar Delavan-Darien para que administre medicamentos al estudiante mencionado arriba. Nombre del medicamento:_____________________________________________________________________ Dosis que debe ser administrada:__________________________________________________________________ Hora en que debe ser administrada :________________________________________________________________

Firma del Padre/Tutor __________________________________________________ Fecha: _________________