Authorization to Dispense External Preparations"*" indicates required fields590-1-1-.20(1) Parental Authorization. Except for first aid, personnel shall 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 Briracliff Daycare Centre 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.Band-aids* Yes NoBaby Wipes* Yes NoNeosporin or similar ointment* Yes NoBactine or similar first aid spray* Yes NoSunscreen* Yes NoInsect Repellent* Yes NoNon-Prescription ointment (such as A & D, Desitin, Vaseline)* Yes NoBaby Powder* Yes NoOther (please specify)Child's Name*Date of Birth* MM slash DD slash YYYY Parent/Guardian Name*Relationship to the Child*Email Address*A copy of the completed form will be sent to this email address. Enter Email Confirm Email NameThis field is for validation purposes and should be left unchanged.Δ
