LICE TREATMENT VERIFICATION FORM

PLEASE RETURN THIS FORM TO THE SCHOOL.

I have treated my child, with

, shampoo on

Parent or Guardian Signature

.

Date

PLEASE RETURN THIS FORM TO THE SCHOOL AFTER THE SECOND TREATMENT HAS BEEN COMPLETED IN EIGHT TO TEN DAYS.

I have treated my child, with

, shampoo on

Parent or Guardian Signature

.

Date