Childcare Topical Cream Consent Form
Use this form to provide permission and instructions for applying a topical cream to your child in childcare.
Child Information
Child's Name
*
First Name
Last Name
Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Room / Class / Group
Parent / Guardian Name and Relationship to Child
*
Topical Cream Details
Cream / Product Name
*
Reason for Use
*
Please Select
Rash
Itching
Dry Skin
Eczema
Insect Bite
Other
Application Location
*
Please Select
Face
Arms
Legs
Hands
Feet
Torso
Diaper Area
Scalp
Other
Application Instructions, Dosage, and Frequency
*
Start Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
End Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Source of Cream
*
Prescribed by Healthcare Provider
Provided by Parent/Guardian
Health and Safety Information
Allergies or sensitivities to cream ingredients or topical products
*
None known
Fragrances
Dyes/Colorants
Lanolin
Petrolatum
Preservatives
Herbal or botanical ingredients
Latex
Other
Known skin reactions or side effects to watch for
*
Special precautions or notes for staff
Emergency and Caregiver Contact
Primary Parent/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Emergency Contact Name
*
First Name
Middle Name
Last Name
Secondary Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Method and Time to Reach Parent/Guardian
Phone call
Text message
Email
Morning
Afternoon
Evening
Anytime
Consent and Authorization
I authorize childcare staff to apply the specified topical cream as instructed
*
I Agree
I Do Not Agree
Submit
Should be Empty: