Print, sign and return the signed paper copy to the Redeemer Lutheran School office.

SUNSCREEN For Redeemer Lutheran School

Lancaster, Ohio

Ohio Department of Children & Youth

REQUEST FOR ADMINISTRATION OF MEDICATION

Child Care Centers and Type A Homes

This form is valid for no longer than twelve (12) months.

Name of child:

Date of birth:

Weight:

Name of medication:

Exact Dosage:

To be administered at the following times: Before Outdoor Play

For the following period of time:

Parent / Guardian signature:

Date:

*Sunscreen must be applied at least once at home
to avoid any unexpected reactions.

This form must be used by child care centers to meet the requirement of OAC Rule 5180: 2-12-25

(Rev. 1/2/25)