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Nombre del alumno: ______________________________________________________________

Sala: ______________

Fecha: ____/____/____ Hora: ____________________

Motivo de la consulta:______________________________________________________________

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Seguimiento:_____________________________________________________________________
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Compromiso:_____________________________________________________________________
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¿Se resolvieron sus dudas? _________________________________________________________

Nombre y firma Padre de familia o persona autorizada:__________________________________

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Nombre y firma del personal de Cendi que atiende:_____________________________________

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