590 1-1 20(1)

Parental authorization, except for first aid, personnel should not dispense prescription or non-prescription medications to a child without specific written authorization from the child s physician or parent. such authorization will include, when applicable. date; full name of the child; name of the medication; prescription number, if any; dosage; the dates to be given; the time of day to be dispensed; and signature of parent

I give (name of authorized person(s)

Permission to apply one or more of the following topical
ointments/preparations to my child in accordance with the directions
on the label of the container.

BABY WIPES

BAND-AIDS

NEOSPORIN OR SIMILAR OINTMENTS

BACTIN OR SIMILAR FIRST AID SPRAY

SUNSCREEN

INSECT REPELLENT

NON-PRESCRIPTION OINTMENT (SUCH AS A &D, DESITIN, VASELINE)

BABY POWDER

Other (please specify)

Parent/guardian check

Date