Sunscreen from Home

Sunscreen Authorization Form

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

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name of Sunscreen & SPF
Sunscreen Expiration Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Active ingredient
Start Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Stop Date: (up to 12 months after 'Start Date')

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent/Guardian Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: