Sunscreen from Home

Sunscreen Authorization Form

(Sunscreen Brought from Home)
Child's First & Last Name*
Date of Birth*

MonthDayYear
Date
Name of Sunscreen & SPF*
Sunscreen Expiration Date*

MonthDayYear
Date
Active ingredient*
Start Date*

MonthDayYear
Date
Stop Date: (up to 12 months after 'Start Date')*

MonthDayYear
Date
Possible Side Effects*
Special Instructions: (Include previous sunscreen reactions)*
I acknowledge that my child is able to independently apply their own sunscreen as needed throughout the day. (Staff can assist with reminders but not application.)
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: