Form DCF-2304 "Wilderness School - Prescription Medication Authorization (Pediatric)" - Connecticut

What Is Form DCF-2304?

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-2304 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-2304 "Wilderness School - Prescription Medication Authorization (Pediatric)" - Connecticut

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Connecticut Department of Children and Families
WILDERNESS SCHOOL – PRESCRIPTION MEDICATION AUTHOPRIZATION (PEDIATRIC)
DCF-2304
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 medications ordered by my child/youth’s physician below be administered to my child/youth as described and directed below, including those medications designated for self-administration.
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:
Side effects and
Allergies, reactions
Self-
Date of Order
Times of
Specific
Controlled
Medication
Dosage & Frequency
Route
plan for
/ interactions with
Administered
(Start / stop if
Prescriber’s Signature
Administration
Instructions
Medication?
management
food / drugs
?
applicable)
Yes
Yes
No
No
Yes
Yes
No
No
Yes
Yes
No
No
Yes
Yes
No
No
Yes
Yes
No
No
Connecticut Department of Children and Families
WILDERNESS SCHOOL – PRESCRIPTION MEDICATION AUTHOPRIZATION (PEDIATRIC)
DCF-2304
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 medications ordered by my child/youth’s physician below be administered to my child/youth as described and directed below, including those medications designated for self-administration.
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:
Side effects and
Allergies, reactions
Self-
Date of Order
Times of
Specific
Controlled
Medication
Dosage & Frequency
Route
plan for
/ interactions with
Administered
(Start / stop if
Prescriber’s Signature
Administration
Instructions
Medication?
management
food / drugs
?
applicable)
Yes
Yes
No
No
Yes
Yes
No
No
Yes
Yes
No
No
Yes
Yes
No
No
Yes
Yes
No
No