Form DCF-2305 "Wilderness School - Prescription Medication Authorization (Psychiatric)" - Connecticut

What Is Form DCF-2305?

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-2305 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-2305 "Wilderness School - Prescription Medication Authorization (Psychiatric)" - Connecticut

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Connecticut Department of Children and Families
WILDERNESS SCHOOL – PRESCRIPTION MEDICATION AUTHOPRIZATION (PSYCHIATRIC)
DCF-2305
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 that the medication listed below be administered to my child/youth as described and directed below
Parent/Guardian Signature
Date
Name of Prescribing Physician/APRN/PA:
Phone:
Address (No. and Street):
City:
State:
Zip:
Please complete chart below, in detail, for each prescribed medication and sign for each medication ordered:
Allergies, reactions /
Date of Order
Dosage &
Times of
Side effects and plan
Controlled
Medication
Route
Specific Instructions
interactions with food /
(Start / stop if
Prescriber’s Signature
Frequency
Administration
for management
Medication?
drugs
applicable)
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Connecticut Department of Children and Families
WILDERNESS SCHOOL – PRESCRIPTION MEDICATION AUTHOPRIZATION (PSYCHIATRIC)
DCF-2305
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 that the medication listed below be administered to my child/youth as described and directed below
Parent/Guardian Signature
Date
Name of Prescribing Physician/APRN/PA:
Phone:
Address (No. and Street):
City:
State:
Zip:
Please complete chart below, in detail, for each prescribed medication and sign for each medication ordered:
Allergies, reactions /
Date of Order
Dosage &
Times of
Side effects and plan
Controlled
Medication
Route
Specific Instructions
interactions with food /
(Start / stop if
Prescriber’s Signature
Frequency
Administration
for management
Medication?
drugs
applicable)
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No