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:*

SunscreenInsect RepellantDiaper Cream
Sunscreen Brand:*
Expiration Date:*

MonthDayYear
Insect Repellant Brand:*
Expiration Date:*

MonthDayYear
Diaper Cream Brand:*
Expiration Date:*

MonthDayYear
Please apply the diaper cream:*

Every diaper changeOnly after a wet diaperOnly after a bowel movementOnly as needed, as indicated by red or visible rash on the skinOther
Parent/Guardian Full Name:*
Signature:*

Powered by Jotform SignClear
Should be Empty: