Clara Barton Center for Children Topical Basic Care Product Application Authorization Form

Topical basic care products such as a diaper rash product, sunscreen, or insect repellent, authorized and supplied by the child’s parent, may be applied without prior approval of a licensed health care practitioner.

You MUST Submit before leaving this form or ALL entries will be lost.

Child

Enter the child's full name (example: use Joseph not Joe)

First name *

Last name *

Date of birth * +

Enter the names of the products you will supply

Diaper rash product

Sunscreen

Insect repellent

I authorize the child care staff to apply and store the topical basic care product as indicated above per the manufacturers’ instructions. I attest that I have administered at least one application of the product to my child without adverse effects. I certify that I have the legal authority to consent to the application and storage of the product(s) for the child named above.

Electronic signature *

Telephone *

Signature date *