Over-The-Counter Topical Permission Form

OVER-THE-COUNTER TOPICAL MEDICATIONS PERMISSION FORM

Please remember that sunscreen/creams provided from home MUST be in the original container with ingredients listed and with the child's name clearly written on the outside of the container.
Medication Administration Permission for Over-the-Counter Topical Medications and Fluoridated Toothpaste

Parent/guardian must authorize staff to apply over-the-counter, topical ointments, topical teething ointment or gel, insect repellents, lotions, creams, powders and fluoridated toothpaste. Sunscreen and baby lotion are examples. Only accept items in their original containers and clearly labeled with the child’s name. Keep insect repellents in locked storage and all other items out of reach of children when not in use.
Child's Name *
Permission is given to apply the following (name/type) *
Please write the name of the cream here (EX: DESITIN® Daily Defense Cream)
Amount *
Please be specific (Ex: pea-sized, quarter sized, etc)
Permission may be given for up to 12 months.
Permission valid from: *

Month Day Year
Date
To: *

Month Day Year
1 year from today's date
Where to apply the ointment, repellent, lotion, cream, or powder: *

all exposed skin face only diaper area
When to apply the ointment, repellent, lotion, cream, or powder: *

before going outside after a bowel movement after each diaper change
Describe how to apply the ointment, repellent, lotion, cream, or powder. *
I give permission to my child care provider to apply the medication listed above as instructed:
Parent/guardian name *
Parent/guardian signature *

Clear
Date *

Month Day Year
Date
NC Child Care Health and Safety Resource Center and NC DHHS DCDEE Updated November 2017
Should be Empty:

OVER-THE-COUNTER TOPICAL MEDICATIONS PERMISSION FORM