Sunscreen Permission Form (Summer 2020)

(Program-Provided/Bulk Sunscreen)

Name of Child*
First Last
Date of Birth*
Date Format: MM slash DD slash YYYY
Start Date:*
Date Format: MM slash DD slash YYYY
Stop Date: (up to 12 months after 'Start Date'*
Date Format: MM slash DD slash YYYY
Special Instructions: (Include previous sunscreen reactions)
Name of Parent*
First Last
Parent Email*
Parent Phone Number*
*
- I authorize the use of the following "program-provided" sunscreen (Rocky Mountain Sunscreen - https://www.rmsunscreen.com/kidssunscreen.aspx) on my child.
Today's Date*
Date Format: MM slash DD slash YYYY
Signature*
Name of Sunscreen & SPF: Rocky Mountain Sunscreen SPF 50
Active Ingredients: Avobenzone—3.0%, Homosalate—15.0%, Octisalate— 5.0%, Octocrylene—10.0%

Possible Side Effects:

Other Label Information: Inactive Ingredients: Acrylates/Octylacrylamide Copolymer, Alcohol Denat., Caprylic/Capric Triglyceride, Diethylhexyl Syringylidenemalonate, Glycerin, Stearoxytrimethylsilane, Tocopherol.

Rocky Mountain Sunscreen lotions and sprays do not include:
- Oxybenzone
- Octinoxate
- Nut oil
- Gluten
- Glycol
- PABA
- Casein
- Silicone
- Retinyl Palmitate
Reason for medication: Protection from sun

Amount to be given: Cover exposed areas of skin

Route: Topical

Times to be applied: 30 mintues before exposure to the sun, and reapplied every two hours if remaining outdoors.

Storage: Room temperature

Bellevue Montessori School