Sunscreen Authorization Form
(Sunscreen Brought from Home)
Child's First & Last Name
*
Date of Birth
*
/
Month
/
Day
Year
Date
Name of Sunscreen & SPF
*
Sunscreen Expiration Date
*
/
Month
/
Day
Year
Date
Active ingredient
*
Start Date
*
/
Month
/
Day
Year
Date
Stop Date: (up to 12 months after 'Start Date')
*
/
Month
/
Day
Year
Date
Possible Side Effects
*
Special Instructions: (Include previous sunscreen reactions)
*
Parent/Guardian Signature
*
Date
*
/
Month
/
Day
Year
Date
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Should be Empty: