Form DCF-2140 "Authorization for out-Of-State Travel for a Foster Child" - Connecticut

What Is Form DCF-2140?

This is a legal form that was released by the Connecticut State Department of Children and Families - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2017;
  • The latest edition provided by the Connecticut State Department of Children and Families;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DCF-2140 by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Children and Families.

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Download Form DCF-2140 "Authorization for out-Of-State Travel for a Foster Child" - Connecticut

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Connecticut Department of Children and Families
AUTHORIZATION FOR OUT-OF-STATE TRAVEL FOR A FOSTER CHILD
DCF-2140
06/2017 (Rev.)
Page 1 of 1
Child’s Last Name:
Child’s First Name:
Child LINK #:
Child’s DOB:
Child’s Medical Insurance Carrier:
Child’s Medical Insurance Policy Number:
Child’s Legal Status:
CPS Committed
Delinquent
Dually Committed
OTC
Protective Supervision
Statutory Parent
Voluntary Services
Caregiver Name:
LINK #:
Caregiver Phone Number:
Caregiver Home Address: (No. and Street):
City:
State:
Zip:
Connecticut
Requesting Social Worker’s Name:
DCF Office:
Date of Request:
Select One
Requesting Social Worker’s Phone Number:
Requesting Social Worker’s E-mail Address:
TRIP SPECIFICS
Overnight with Caregiver
Overnight with:
(Enter Name of Organization):
FROM:
UNTIL:
Date
Time:
Date
Time:
AM
PM
AM
PM
Destination:
Out-of-State Address: (No. and Street):
City:
State:
Zip:
Contact Person:
Telephone number:
Means of Transportation:
Driver’s Operator’s License #:
Auto Insurance Carrier:
Policy #:
CT Auto Insurance?:
Yes
No
APPROVAL
The above-named child has permission to travel out-of-state: (approval not required if trip is for less than forty-eight hours)
PM, PD or Office Director Name:
Date:
Parent / Legal Guardian Name:
Date:
Manager or Director Signature:
Parent / Legal Guardian Name Signature:
EMERGENCY MEDICAL PERMISSION
A medical provider or facility MUST make reasonable efforts to obtain verbal permission from the Department of
Children and Families PRIOR to providing emergency medical treatment for a foster child by calling the appropriate
office at (enter phone number) _______________________________ between 8:00 a.m. and 5:00 p.m., Monday
through Friday, or the Careline at 800-842-2288 between 5:00 p.m. and 8:00 a.m. Monday through Friday, or all
day weekends and holidays. If verbal permission cannot reasonably be obtained, a medical provider or facility may
provide emergency treatment as deemed necessary, but DCF MUST be notified as soon as possible thereafter.
Connecticut Department of Children and Families
AUTHORIZATION FOR OUT-OF-STATE TRAVEL FOR A FOSTER CHILD
DCF-2140
06/2017 (Rev.)
Page 1 of 1
Child’s Last Name:
Child’s First Name:
Child LINK #:
Child’s DOB:
Child’s Medical Insurance Carrier:
Child’s Medical Insurance Policy Number:
Child’s Legal Status:
CPS Committed
Delinquent
Dually Committed
OTC
Protective Supervision
Statutory Parent
Voluntary Services
Caregiver Name:
LINK #:
Caregiver Phone Number:
Caregiver Home Address: (No. and Street):
City:
State:
Zip:
Connecticut
Requesting Social Worker’s Name:
DCF Office:
Date of Request:
Select One
Requesting Social Worker’s Phone Number:
Requesting Social Worker’s E-mail Address:
TRIP SPECIFICS
Overnight with Caregiver
Overnight with:
(Enter Name of Organization):
FROM:
UNTIL:
Date
Time:
Date
Time:
AM
PM
AM
PM
Destination:
Out-of-State Address: (No. and Street):
City:
State:
Zip:
Contact Person:
Telephone number:
Means of Transportation:
Driver’s Operator’s License #:
Auto Insurance Carrier:
Policy #:
CT Auto Insurance?:
Yes
No
APPROVAL
The above-named child has permission to travel out-of-state: (approval not required if trip is for less than forty-eight hours)
PM, PD or Office Director Name:
Date:
Parent / Legal Guardian Name:
Date:
Manager or Director Signature:
Parent / Legal Guardian Name Signature:
EMERGENCY MEDICAL PERMISSION
A medical provider or facility MUST make reasonable efforts to obtain verbal permission from the Department of
Children and Families PRIOR to providing emergency medical treatment for a foster child by calling the appropriate
office at (enter phone number) _______________________________ between 8:00 a.m. and 5:00 p.m., Monday
through Friday, or the Careline at 800-842-2288 between 5:00 p.m. and 8:00 a.m. Monday through Friday, or all
day weekends and holidays. If verbal permission cannot reasonably be obtained, a medical provider or facility may
provide emergency treatment as deemed necessary, but DCF MUST be notified as soon as possible thereafter.