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

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.