Topical Application Permission Form

[INTERNAL] Enter the Academic Year for which this form is being filled out:
As the parent of:
Child's First & Last Name
I give my permission for the staff of The Rosen JCC Early Childhood Learning Center (ECLC) to apply product to my child, as specified below, when he or she will be engaging in outdoor activities.
Check all of the topical product(s) which you wish for us to apply:
Sunscreen Brand:
Expiration Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Insect Repellant Brand:
Expiration Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Diaper Cream Brand:
Expiration Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Please apply the diaper cream:

Other
Parent/Guardian Full Name:
Signature:
Should be Empty: