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Permission-Topical Application Administration

Please complete the form below. Required fields marked with an asterisk *

Childs First and Last Name

Answer required for "Childs First and Last Name"

I understand that topical applications such as lip balms, lotions, diaper cream, ointment, corn starch/corn starch powders can be applied only as preventative measure. Where required by licensing application to open, oozing sores or continued or persistent diaper rash requires a medication administration form signed by me and the child's physician.

*No Aerosol sprays

I understand that the topical ointment provided by me must

-Be appropriate for use on child

-Be applied accordingly to the instructions on the label

-Be labeled with the child's full name

-Be handed to a staff member and not left in a diaper bag or cubby.

I give permission for stafff at AXIS to apply: (Teacher's name)

Answer required for "I give permission for stafff at AXIS to apply: (Teacher's name)"

As needed from today's Date:

Answer required for "As needed from today's Date:"

to not to exceed one year

10/23/2020

Answer required for "to not to exceed one year"

Parent Signature

Answer required for "Parent Signature"

Today's Date:

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