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Msgr. McClancy Memorial High School 71-06 31ST Avenue East Elmhurst NY 11370 718 898-3800 SELF-MEDICATION RELEASE FORM Date Student s Name has been instructed in the proper use of the following medication procedures We Physician s signature and Parent or Guardian s signature request that Student s name be permitted to carry the medication on his/her person as we consider him/her responsible. He/She has been instructed in and understands the purpose and appropriate method and frequency of use....
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