Sunscreen & Insect Repellent

Non-Prescription Topical Medication Authorization Form

For Sunscreen and Insect Repellent

I hereby request that the following non-prescription topical medications be administered to my child by School Bell.

I understand that I must provide School Bell with the sunscreen and/or insect repellent in the original container, clearly labeled with:

My child’s name
The name of the product
Directions for use

Spray products are not allowed. All products must be within their expiration date.

This form authorizes the following topical medications to be applied:

Sunscreen (non-spray)
Insect repellent (non-spray; for children over 2 months old, applied once daily)

Name of Child(Required)

First Last

Today's Date(Required)

Child's Birthdate

Select School Bell Location(Required)

Brighton

Highland

This form authorizes the following topical medications to be applied:(Required)

Sunscreen (non-spray)

Insect Repellent (non-spray; children over 2 months only)

Both

Name of Sunscreen(Required)

Directions for Suncreen Application(Required)

Name of Insect Repellent(Required)

Directions for Insect Repellent(Required)

Authorization

By typing my name below, I acknowledge that this serves as my electronic signature and authorize School Bell to apply the non-prescription topical medications listed above as directed.

Name of Parent/Guardian(Required)

First Last

Email(Required)

A copy of this form will be emailed to you at:

School Bell Locations

School Bell Programs

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