Sakun si ___________________________________________ a luks I _____________________________________

(Name of Parent / Guardian) (Name of Child)

Grade ____________________ sa a meniyog ako a pakiporga akun giya a wata
(Name of School)
akun. Giya wata akun na dabaniyan pukagudam sa giya mga kisusurat;

( ) da mayaw nian (no fever)

( ) kunaba pusakit a tiyan iyan (no abnominal pain)
( ) kunaba de magodowa (no severe diarrhea)
( ) da maporga sa solud a miyaka 6 ulan aya (not dewormed within 6 months)

__________________________________________
Name & Signature of Parent / Guardian

Noted by: ______________________________________

Name & Signature of Teacher

Autonomous Region in Muslim Mindanao

Department of Education
DIVISION OF LANAO DEL SUR

Sakun si ___________________________________________ a luks I _____________________________________

(Name of Parent / Guardian) (Name of Child)
Grade ____________________ sa LILOD-RAYA PILOT ELEMENTARY SCHOOL a meniyog ako a pakiporga akun giya a wata
(Name of School)
akun. Giya wata akun na dabaniyan pukagudam sa giya mga kisusurat;

( ) da mayaw nian (no fever)

( ) kunaba pusakit a tiyan iyan (no abnominal pain)
( ) kunaba de magodowa (no severe diarrhea)
( ) da maporga sa solud a miyaka 6 ulan aya (not dewormed within 6 months)

__________________________________________
Name & Signature of Parent / Guardian

Noted by: ______________________________________

Name & Signature of Teacher