Form DCF-2303 "Non-prescription Medication Authorization (Otc)" - Connecticut

What Is Form DCF-2303?

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 January 1, 2018;
  • 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-2303 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-2303 "Non-prescription Medication Authorization (Otc)" - Connecticut

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Connecticut Department of Children and Families
WILDERNESS SCHOOL – NON-PRESCRIPTION MEDICATION AUTHOPRIZATION (OTC)
DCF-2303
1/18 (Rev.)
Page 1 of 1
In Connecticut, Youth Camps administering medications to children shall comply with all requirements regarding the Administration of Medications described in the State Statutes and OEC Regulations. Parents/guardians
requesting medication administration to their child shall provide the program with appropriate written permission and the medication(s) before any medications may be administered. Medications must be in the original
container and labeled with child’s name, name of medication, directions for medication’s administration, and date of the prescription, if applicable. Medications must be delivered to the Wilderness School ninety-six (96)
hours prior to the course start.
Student LAST Name:
Student FIRST Name:
DOB:
Address (No. and Street):
City:
State:
Zip:
Parent/Guardian LAST Name:
Parent/Guardian FIRST Name:
Relationship:
Address (No. and Street, if different from above):
City:
State:
Zip:
To the parent/guardian:
I give permission for the medication(s) listed below be administered to my child/youth as described and directed.
I give permission (please also check below) for non-prescription topical medications that may be provided by Wilderness School staff and do not require doctor’s orders or prescription:
Ointments free of antibiotic, antifungal or steroidal components
Parent/Guardian Signature
Date
Medicated powders available without prescription
Name of Prescribing Physician/APRN/PA:
Phone:
Address (No. and Street):
City:
State:
Zip:
Please complete in detail for each medication that is prescribed and sign for each medication ordered:
Allergies, reactions /
Date of Order
Times of
Side effects and plan
Medication
Dosage & Frequency
Route
Specific Instructions
interactions with food /
(Start/stop if
Prescriber’s Signature
Administration
for management
drugs
applicable)
Connecticut Department of Children and Families
WILDERNESS SCHOOL – NON-PRESCRIPTION MEDICATION AUTHOPRIZATION (OTC)
DCF-2303
1/18 (Rev.)
Page 1 of 1
In Connecticut, Youth Camps administering medications to children shall comply with all requirements regarding the Administration of Medications described in the State Statutes and OEC Regulations. Parents/guardians
requesting medication administration to their child shall provide the program with appropriate written permission and the medication(s) before any medications may be administered. Medications must be in the original
container and labeled with child’s name, name of medication, directions for medication’s administration, and date of the prescription, if applicable. Medications must be delivered to the Wilderness School ninety-six (96)
hours prior to the course start.
Student LAST Name:
Student FIRST Name:
DOB:
Address (No. and Street):
City:
State:
Zip:
Parent/Guardian LAST Name:
Parent/Guardian FIRST Name:
Relationship:
Address (No. and Street, if different from above):
City:
State:
Zip:
To the parent/guardian:
I give permission for the medication(s) listed below be administered to my child/youth as described and directed.
I give permission (please also check below) for non-prescription topical medications that may be provided by Wilderness School staff and do not require doctor’s orders or prescription:
Ointments free of antibiotic, antifungal or steroidal components
Parent/Guardian Signature
Date
Medicated powders available without prescription
Name of Prescribing Physician/APRN/PA:
Phone:
Address (No. and Street):
City:
State:
Zip:
Please complete in detail for each medication that is prescribed and sign for each medication ordered:
Allergies, reactions /
Date of Order
Times of
Side effects and plan
Medication
Dosage & Frequency
Route
Specific Instructions
interactions with food /
(Start/stop if
Prescriber’s Signature
Administration
for management
drugs
applicable)