Little Flower - Day Care Center & Preparatory School in Brooklyn

No medication can be administered without the signed permission
of a parent or guardian.
Please fill out the form, print and return it to the school office.

Child's Full Name:
Age:
Doctor's Name:
Doctor's Telephone:
Name of medication:
Amount to be administered:
Time medication to be administered:
from (date): to (date):

In Case Of Emergency - Please Contact:


Mr.
Mrs.
Ms.
Miss
  Full Name:
Relationship To Parent:
Street address:
City:      State:      Zip Code:
Telephones:
Work Home: Cell.:

_______________________________________        ___________________
Parent/Guardian Signature                                         Date

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