Program-Provided Sunscreen Form

Sunscreen Authorization Form

(Program-Provided/Bulk Sunscreen)
LASER Childcare provides the following sunscreen: Banana Boat for Kids SPF 50
- Expiration Date: None Listed
- Active Ingredients: Titanium Dioxide 3.1%, Zinc Oxide 4.0%
- Side Effects: None listed
- Reason for medication: Protection from sun
- Amount to be given: Cover exposed areas of skin
- Route: Topical
- Times to be applied: 30 minutes before exposure to the sun, and reapplied every two hours if remaining outdoors.
- Storage: Room temperature
Child's First and Last Name*
Date of Birth*

MonthDayYear
Date
Start Date of Sunscreen Application*

MonthDayYear
Date
Stop Date of Sunscreen Application (up to 12 months after 'Start Date')*

MonthDayYear
Date
Special Instructions: (Include previous sunscreen reactions)
I authorize the use of the following "program-provided" sunscreen on my child.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: