Medicine Permission Form Child #1 Information First Last Grade Child #2 Information (Leave Blank if not Applicable) First Last Grade Child #3 Information (Leave Blank if not Applicable) First Last Grade Medicine PermissionI request the school to give the medication listed, to the above mentioned student(s), if needed during the school year (Please check all that apply): Cough Drops (cough, sore throat) Hydrocortisone Cream (Skin Irritation) Triple Antibiotic/Neosporin (Minor Wounds) SignatureDate MM slash DD slash YYYY
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