Depot Daycare

Lotion Release Form

Name of Child:   

Name of Lotion or Sunscreen:   


Name of Diaper Cream:   

            No Baby Powders at Depot Daycare

Condition Being Treated:   

Examples are for sun protection, sore bum and dry skin

Times Lotion needs to be applied:   

Date Lotion expires:   

Possible Side Effects:   

I hereby give my permission for the provider to administer this medication according to the instructions above. I agree that the provider will not be held liable for any illness or injury resulting from the administration of this medication, and will not be held responsible for the reimbursement of any medical expenses resulting from such action.

Signature of Parent or Guardian

Leave this empty:

Signature arrow sign here

Signature Certificate
Document name: Lotion Release Form
lock iconUnique Document ID: 00eccfd69246b4dab38f2390843d3aa981c19df3
Timestamp Audit
March 29, 2018 11:03 am MDTLotion Release Form Uploaded by Ty Singleton - IP