Insect Repellent Permission Form

I, hereby give Countryside Montessori School, Inc. and its employees permission to apply the following insect repellent onto my child as needed.

Date

YYYY

Child's Name

First Name

Last Name

School's Provided Insect Repellent

Greenerways Organic Insect Repellent, DEET-Free, Premium, USDA Organic, Non-GMO, Natural Mosquito-Repellent, Bug Repellant, Bug Spray, Clothing Safe, Kid Safe, Pet Safe, Baby Safe, Pest Control

Yes, as needed

No, I will provide insect repellent

I will provide the following Insect Repellent:

Has your child exhibited any side effects to this insect repellent?

Yes

If, yes please explain:

Signature

Electronic Signature