Authorizations must be re-submitted annually. 

By submitting the form below, you authorize ChildRoots staff to:

  • Treat small abrasions with an antibacterial solution and a bandage.
  • Reapply family-provided sunscreen to "hot spots" in the afternoon during the summer months.
  • Apply family-provided diaper creams and lotions.
  • Administer family-provided emergency medication (EpiPen, inhalers) in emergency situations.
  • Provide emergency health services, including but not limited to the use of CPR, first aid, ambulance transport, and hospitalization.
  • Take classroom walking excursions with teachers.

ChildRoots staff will not administer any non-emergency medication. Medication required while your child is in care must be administered by a parent or guardian. 

Child Name *
Child Name
Parent Name *
Parent Name
Date *