Diaper Cream Permission Form — Countryside Montessori School

Authorization for Non-prescription Over-the-Counter Skin Products

I, hereby give Countryside Montessori School, Inc. and its employees permission to apply the following “diaper cream” onto my child as needed.

Child's Name

First Name

Last Name

I will provide the following diaper cream (product name):

Known adverse reactions (if any):

This authorization is effective from:

MM

DD

YYYY

Until:

MM

DD

YYYY

Signature

Electronic Signature

Date

MM

DD

YYYY

ALL OTC products must:

Be in the original container
Labeled with child’s name
Be within the expiration date