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MEDICATION FORM
Name of Student______________________________ Grade______________ Date__________________ Medication___________________________ Dose____________Times to be taken______________ Length of time to be taken_______________________ Reason for prescription__________________________ Number of pills in bottle________________
Parent Signature_______________________________
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GYM EXCUSE
Name of Student______________________________ Grade____________ Date_________________ Reason for excuse____________________________ Length of excuse_____________________________ (longer than a week requires a doctor’s note) Parent Signature______________________________
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To contact us: |
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Phone: 302-654-2495 Fax: 302-654-7767 Email: jawest@salesianum.org |
