Parent/guardian Permission To Apply Insect Repellent To Child Form

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Parent/Guardian Permission to Apply Insect Repellent to Child
Name of Child: ____________________________________________________________________________
As a parent, I recognize that insect bites to my child pose a risk of allergic reactions and disease.
Therefore, I give permission for the staff of _____________________________________________ to apply
name of child care program
name of child care program
an insect repellent approved for use on children (name of product)________________________________
to my child under the following conditions:
1. When mosquitoes are present.
2. During field trips that may expose a child to ticks or mosquitoes.
3. Always used according to directions on the label.
4. Applied only to exposed skin and clothes.
5. Not applied to babies under 2 months.
6. Not applied near eyes or mouth or on hands.
Use of the insect repellent products may occasionally cause a skin reaction. If that happens, we will
discontinue use of the product, wash affected skin and notify you so you can seek advice from your
health care provider. It is best if you use this or a similar product on your child once or twice at home
first to monitor for reactions.
I have checked and initialed below all applicable information regarding the child care program’s choice
in brand/type and use of insect repellent for my child:
❏ ___ Staff may use the program’s insect repellent indicated above according to the directions on the
product label.
❏ ___ I do not know of any allergies my child has to children’s insect repellent.
❏ ___ My child is allergic to some insect repellents. Please use only the following brand(s)/type(s) of
repellent: ______________________________________, according to the directions on the label.
❏ ___ I have provided the following brand/type of insect repellent for use on my child: ____________
____________________________________________________________________________________
❏ ___ For medical or personal reasons, please DO NOT apply insect repellent to the following areas of
my child’s body: _____________________________________________________________________
❏ ___ Please do not apply insect repellent to my child.
Parent/Guardian’s Name: ___________________________________
Date: ________________________
Parent/Guardian’s Signature: ________________________________________________________________
Health Provider’s Signature (optional): ________________________________________________________
UCSF California Childcare Health Program • cchp.ucsf.edu
Rev. 05/16

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