Authorization Form for Non-Prescription Over-the-counter Skin Products

Mountain Laurel Montessori School Authorization Form for Non-Prescription Over-the-Counter Skin Products
Mountain Laurel does not provide over-the-counter skin products or medications. This form is to be used for a specific non-prescription over-the-counter skin care product specified below; as provided by the parent/guardian.

INSTRUCTIONS: one product per form only

This form must be completed by the parent/guardian to authorize the use of:
- Sunscreen
- Over-the-counter hand/body lotion, lip balm or hand sanitizer
- Insect repellent
Any other type of medication(s) must be submitted with the "Medication Authorization" form.

All products and medications must be submitted directly to a staff member. Do not send any products or medication in your child's backpack.
Mountain Laurel Montessori School has my permission to apply the non-prescription over-the-counter (OTC) skin product listed below to my child.
Child*

First NameLast Name
Complete Product Name*
Product Expiration Date*
Product/medication must have an expiration date on the bottle/box and must not be expired.
Known Adverse Reactions (if any)
This product is to be applied: (check all that apply)*

HeadHairLipsFaceArmsLegsHandsTorsoExposed skinOn clothingAffected areaOther
Time this product is to be applied: (check all that apply)*

Morning arrivalBefore going outsideBefore going into the woodsBefore dismissalOther
All OTC products must:
- Be in the original container and labeled with the child's name
- Be used according to manufacturer's recommendation and instructions for application
- Not be used beyond the expiration date of the product
- Have a record of use kept that includes child's name, date, frequency of application, and any adverse reactions
Sunscreen:
- Any MLMS provided sunscreen will have a minimum sunburn protection factor (SPF) of 15
- Shall be inaccessible to children
- Children nine years and older may self-administer sunscreen with a written authorzation from a physician and parent
- Children will be supervised by a staff member when self-administering sunscreen
Diaper ointment/cream and insect repellents:
- Shall be kept inaccessible to children
This authorization is effective from: Date* until: Date*
Parent or Guardian *

First NameLast Name
Email*
example@example.com
Parent or Guardian Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Mountain Laurel Montessori School Authorization Form for Non-Prescription Over-the-Counter Skin Products