2023-24 DCP Topical Preparations (Preventive) Permission Form

Denver Cooperative Preschool Topical Preparations (Preventive) Permission Form
This form covers a variety of preventive topical preparations that may be applied to the skin with parent/guardian permission
Child's Name:*
Parent/Guardian's Name:*
Parent/Guardian's Email:*
SUNSCREEN
I give my permission for the staff at DCP to assist with applying or apply sunscreen to my child's exposed skin including the face, tops of ears and bare shoulders, arms, legs and feet 30 minutes before outdoor activities. Sunscreen will not be applied to any broken skin or if a skin reaction has been observed. Any skin reaction observed by staff will be reported promptly to the parent/guardian.*

The school may apply Rocky Mountain Sunscreen SPF 30 to my child. I understand that it is my responsibility to check the ingredients of this product to ensure my child is not allergic to it.My child may NOT use any sunscreen other than the one that he/she brings. It is my responsibility to provide sunscreen with a minimum SPF of 15. I understand I must provide the sunscreen in its original container labeled with my child’s name and within the noted expiration date.
Special instructions:
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
MOISTURIZING LOTION/CREAM/BALM
I give my permission for the staff at DCP to assist with applying or apply skin lotion/cream to my child. Skin lotion/cream/balm will not be applied to any broken skin or if a skin reaction has been observed. Any skin reaction observed by staff will be reported promptly to the parent/guardian.*

The school may apply Eucerin – Original Cream to my child. I understand that it is my responsibility to check the ingredients of this product to ensure my child is not allergic to it.My child may NOT use any other skin lotion/cream/balm than the one he or she brings. I understand I must provide the lotion/cream/balm in the original over the counter container labeled with my child’s name. It is my responsibility to check the ingredients of this product to ensure my child is not allergic to it
Special instructions:
Date:

MonthDayYear
Date
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
DIAPER OINTMENT/CREAM
I give my permission for the staff at DCP to apply over the counter diaper rash ointment to my child. Ointment/cream will not be applied to any broken skin or if a skin reaction has been observed. Any skin reaction observed by staff will be reported promptly to the parent/guardian.*

The school may apply Balmex Cream 11.3% Zinc Oxide to my child. I understand that it is my responsibility to check the ingredients of this product to ensure my child is not allergic to it.My child may NOT use any other diaper ointment/cream than the one he or she brings. I understand that I may only provide diaper ointment or cream, free of antibiotic, antifungal or anti-inflammatory components without a written prescription from my doctor. I understand I must provide the ointment/cream in the original over the counter container labeled with my child’s name.
Specia instructions:
Parent/Guardian Signature:*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Denver Cooperative Preschool Topical Preparations (Preventive) Permission Form

SUNSCREEN

MOISTURIZING LOTION/CREAM/BALM

DIAPER OINTMENT/CREAM