Insect Repellent Authorization Form

Authorization Form for Non-Prescription Over-the-Counter Skin Products

This form must be completed by the parent/guardian to authorize the use of Insect Repellent.

Please fill out this form before sending in insect repellent. All OTC products must be in the original container, and labeled with the child’s name.

Arlington Montessori House has my permission to apply the non-prescription over-the-counter (OTC) skin product(s) listed below to my child,

Child's name

Insect Repellent Product Name:

Known Adverse Reactions (if any):

Parent's Authorization

First Name

Last Name

Today's Date

**FORM EXPIRES ONE YEAR FROM THIS DATE.

YYYY