Topical Application Permission Form
As the parent of
*
I give my permission for the staff of the Rosen Early Childhood Learning Center to apply products to my child as specified below.
Check all which you wish for us to apply:
Sunscreen
Insect Repellant
Diaper Cream
For medical reasons, please do not apply repellant/sunscreen to my child.
Brand of Sunscreen
Expiration Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Brand of Repellant
Expiration Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Brand of Diaper Cream
Expiration Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please apply diaper cream:
Every diaper change
Only after a wet diaper
Only after a BM
Only as needed as indicated by red or rashy skin as indicated here
Parent/Guardian Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: