1. ALCALDÍA DE PEREIRA
SECRETARÍA DE EDUCACIÓN MUNICIPAL
PROGRAMA DE EDUCACIÓN ESPECIAL
UNIDAD DE ATENCIÓN INTEGRAL
REMISIÓN ESPECIALISTA
FECHA: ……………………………………
I D E N T I F I C A C I Ó N
Nombres y Apellidos
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Lugar y Fecha de Nacimiento: ____________________________ D ____/ M_____/ A _____
Edad: ____________________ Sexo: F M
Institución _________________________________________________________________________________
Grado Escolar: ______________________________ Repitente: SI NO
Nombre de losPadres __________________________________________________
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Dirección/Teléfono:____________________________________________________
REMITIDO A: ________________________________________________________________________________
MOTIVODE REMISIÓN: (Lomás completoposible) _________________________________________________
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OBSERVACIONES:____________________________________________________________________________
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AFILIACIÓN A SALUD:_________________________________________________________________________
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