Physical Activities Acknowledgement and Assumption of Risk and Release 2021-22

Permission to Administer Sunscreen, Insect repellent, Lip balm and Topical OTC Medication Permission Form 2022-23

This form needs to be updated annually. You may do one form for all your children.
Student/Participant 1 Name *

First Name Last Name
Student/Participant 1 Grade for 2022-23 *
Student/Participant 2 Name

First Name Last Name
Student/Participant 2 Grade for 2022-23
Student/Participant 3 Name

First Name Last Name
Student/Participant 3 Grade for 2022-23
Student/Participant 4 Name

First Name Last Name
Student/Participant 4 Grade for 2022-23
PART 1)

This waiver gives River Grove permission to apply sun screen (SPF 15 or higher), lip balm, and/or insect repellent that is supplied from home. The items must be supplied by parent and clearly labeled with the student’s name and grade.
I hereby acknowledge and request that River Grove staff, its employees and/or duly authorized agents administer or assist in administering sunscreen, lip balm, and/or insect repellent to above named child while child is under the supervision of River Grove. In consideration of the administering or assistance in administering sunscreen, lipbalm and/or insect repellent, I hereby forever release, discharge, hold harmless and agree to indemnify River Grove, its employees and duly authorized agents of and from any and all claims, demands, suits, actions, and liabilities or responsibilities of whatsoever kind or nature, arising out of connection with the administering or assistance in administering of said sunscreen, lip balm, and/or insect repellent. I understand that these will be applied only right before and as needed during outdoor play *

YES, for all students named above NO, for all students named above
If you selected "Other" above, please explain in detail:
PART 2) TOPICAL OTC MEDICATION:

In order for over-the-counter (OTC) medications to be given to your child we must have your written permission. This form is in lieu of a telephone call each time your child requires medication. Parents will be notified if the requests for such medication are excessive. Dosing and formulation of medication will be determined by the school nurse and will be age and weight appropriate.
PLEASE INDICATE EACH TOPICAL MEDICATION FOR WHICH YOU ARE GIVING PERMISSION:
yes or no* Antibiotic cream (Bacitracin/Neosporin Triple Antibiotic ointment)
yes or no* Hydrocortisone cream
yes or no* Aquaphor/Vaseline/Lotion
yes or no* Anti-itch cream (Benadryl cream, Caladryl lotion)
yes or no* Cough drop/throat lozenge
If necessary, please add further information regarding topical OTC medications:
Parent/Guardian Signature:
Sign and date (if this electronic signature doesn't work for you, please print and sign the hard copy and return to the school office)

Clear
Full name used in the signature above *
Today's Date

Month Day Year
Please note: This form does not give us permission to administer non-prescription pain relievers such as acetaminophen (Tylenol) or ibuprofen (Advil). Please see the separate form.
Parent Email *
example@example.com
Should be Empty:

Permission to Administer Sunscreen, Insect repellent, Lip balm and Topical OTC Medication Permission Form 2022-23