Form DCF-2300 "Wilderness School Student Application" - Connecticut

What Is Form DCF-2300?

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-2300 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-2300 "Wilderness School Student Application" - Connecticut

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Connecticut Department of Children and Families
WILDERNESS SCHOOL – STUDENT APPLICATION
DCF-2300
1/18 (Rev.)
Page 1 of 4
PART 1 – STUDENT INFORMATION
Student LAST Name:
Student FIRST Name:
DOB:
Age:
Address (No. and Street):
City:
State:
Zip:
Phone:
Student E-mail:
Demographics:
Urban
Suburban
Rural
Student’s Race:
Student’s Ethnicity:
Please Select One
Please Select One
Please Select One
Please Select One
Student’s Gender:
Male
Female
Transgender (M to F)
Transgender (F to M)
Non-Binary
PARENT / LEGAL GUARDIAN INFORMATION
LAST Name:
FIRST Name:
E-mail:
Address (No. and Street, if different from above):
City:
State:
Zip:
Daytime Phone #:
Cell Phone #:
Evening Phone #:
Caregiver Relationship to Child:
Language(s) spoken in home:
Please Select One
Please Select One - or enter your own
EMERGENCY NOTIFICATION IF LEGAL GUARDIAN IS UNAVAILABLE
LAST Name:
FIRST Name:
E-mail:
Relationship:
Please Select One
Daytime Phone #:
Cell Phone #:
Evening Phone #:
LAST Name:
FIRST Name:
E-mail:
Relationship:
Please Select One
Daytime Phone #:
Cell Phone #:
Evening Phone #:
REFERRAL INFORMATION
Referring Agent Name:
Agency Name:
E-mail:
Address (No. and Street, if different from above):
City:
State:
Zip:
Daytime Phone #:
Cell Phone #:
Evening Phone #:
Is another agency involved in this referral:
Yes
No. If yes, please provide agency information below.
Referring Agent Name:
Agency Name:
E-mail:
Address (No. and Street, if different from above):
City:
State:
Zip:
Daytime Phone #:
Cell Phone #:
Evening Phone #:
Connecticut Department of Children and Families
WILDERNESS SCHOOL – STUDENT APPLICATION
DCF-2300
1/18 (Rev.)
Page 1 of 4
PART 1 – STUDENT INFORMATION
Student LAST Name:
Student FIRST Name:
DOB:
Age:
Address (No. and Street):
City:
State:
Zip:
Phone:
Student E-mail:
Demographics:
Urban
Suburban
Rural
Student’s Race:
Student’s Ethnicity:
Please Select One
Please Select One
Please Select One
Please Select One
Student’s Gender:
Male
Female
Transgender (M to F)
Transgender (F to M)
Non-Binary
PARENT / LEGAL GUARDIAN INFORMATION
LAST Name:
FIRST Name:
E-mail:
Address (No. and Street, if different from above):
City:
State:
Zip:
Daytime Phone #:
Cell Phone #:
Evening Phone #:
Caregiver Relationship to Child:
Language(s) spoken in home:
Please Select One
Please Select One - or enter your own
EMERGENCY NOTIFICATION IF LEGAL GUARDIAN IS UNAVAILABLE
LAST Name:
FIRST Name:
E-mail:
Relationship:
Please Select One
Daytime Phone #:
Cell Phone #:
Evening Phone #:
LAST Name:
FIRST Name:
E-mail:
Relationship:
Please Select One
Daytime Phone #:
Cell Phone #:
Evening Phone #:
REFERRAL INFORMATION
Referring Agent Name:
Agency Name:
E-mail:
Address (No. and Street, if different from above):
City:
State:
Zip:
Daytime Phone #:
Cell Phone #:
Evening Phone #:
Is another agency involved in this referral:
Yes
No. If yes, please provide agency information below.
Referring Agent Name:
Agency Name:
E-mail:
Address (No. and Street, if different from above):
City:
State:
Zip:
Daytime Phone #:
Cell Phone #:
Evening Phone #:
WILDERNESS SCHOOL - STUDENT APPLICATION
Page 2 of 4
PART II – CONSENT AND WAIVER
The Wilderness School conducts physically demanding courses of up to twenty days in length. The program is not a summer camp experience. The student must be
emotionally as well as physically prepared for the rigorous demands of the experience. Students participate in back country expeditions that may include hiking, canoeing,
rock climbing, a high ropes course, a service project, an 8.5-mile marathon run and a solo experience. Students sleep in tarps inside sleeping bags for the entire course.
Students carry thirty to fifty pound backpacks on average of eight miles per day and for extended periods.
All participants must be free of all medical or physical conditions that might create undue risk to themselves or others who depend upon them. All medication is supervised
by Wilderness School staff. Wilderness School requires that each youth submit a copy of their State of CT Department of Education, Health Assessment Record dated
within two calendar years of the course start date. There are three Medication Administration forms – one is for Non-Prescription Medication (OTC) - we recommend
that students be authorized for either ibuprofen or acetaminophen as well as anything else that the youth may need. If the applicant is taking any prescription medication
that is prescribed by a Pediatrician, please have the prescriber complete the Medication Authorization (Pediatric) form. If the youth is taking medication prescribed by a
Psychiatrist or mental health professional, please have the prescriber complete the Medication Authorization (Psychiatric).
The Wilderness School provides ample and nutritious meals prepared by the student. Special dietary requirements cannot always be met. All drinking water from natural
sources is purified by boiling or by use of a chemical (iodine) water purification treatment. Personal hygiene and self-care are limited to a primitive wilderness setting
(cold water bathing). Toilet facilities are limited to latrines and outhouses. Expeditions occur in remote areas and in all types of weather, including wind, rain, cold, heat
and electrical storms. Additional environmental hazards include potential exposure to diseases such as Rabies, Lyme disease, or Giardia through contact with animals,
insect bites and stings. Due to the remote environment, contact with students is through mailed correspondence only. While the course is stressful, it is expected that
any person with normal physical and mental abilities can complete the program successfully. The use of tobacco, alcohol, and illicit drugs is prohibited.
Acknowledgement of potential risks, appropriate behaviors, permissions and emergency medications
There are certain inherent risks to be assumed when participating in activities of a physical nature and the student may risk personal
injury. Wilderness School Instructors will inform students of safety rules and will conduct all activities in a safe manner. Students
also have a role in maintaining the safety of the group. Students should call to the attention of the Instructors any situation that
1.
Yes
No
seems to be a possible danger to any Wilderness School student or staff. This could include: A. Broken equipment; B. Feeling sick
or very tired; C. Having considerable trouble performing or learning a skill. I acknowledge that I have been advised of the potential
risks.
We have read the above information and understand the physical and stressful nature of the 20-Day, 7-Day or 5-Day Expedition, and
the nature of the student population. Consent is granted for the student to attend the Wilderness School and to participate in the
2.
Follow-Up activities of the program. As a student, I will wear any required equipment, and follow the directions of the Wilderness
Yes
No
School staff at all times. I understand Behavioral Policy violations or other inappropriate behaviors will lead to removal from the
course
Permission is granted for the student to be transported in a motor vehicle operated by an employee of the Department of Children
3.
Yes
No
and Families to and from Wilderness School activity sites.
Permission is granted by the parent/guardian and student identified above for any medical treatment, emergency anesthesia and/or
4.
operation that might become necessary. For DCF Committed Youth Only: Permission will be obtained from DCF Worker or DCF
Yes
No
Careline for any medical treatment.
Emergency Medications: As allowed by the State Legislature, the Wilderness School Youth Camp Physician will provide standing
orders for Wilderness School Staff to use Epinephrine and Diphenhydramine (i.e. Benadryl) in life threatening emergency situations
5.
in wilderness settings. All staff are trained in emergency use and administration. Medication is supplied by Wilderness School. As
Yes
No
parent/legal guardian, I approve of the use of Epinephrine and Diphenhydramine (i.e. Benadryl) for my son/daughter/ward in the
event of a life threatening emergency.
Student Photo/video Release
Permission is granted for the Department of Children and Families to photograph the below named student and create slide
1
Yes
No
documentation of the Wilderness School course.
Permission is granted to the Department of Children and Families to use the photographs and slides in all aspects of Wilderness School
2
functions including slide shows, orientations and also public information materials such as newsletters, websites, brochures or
Yes
No
pamphlets and newspaper or journal articles.
Permission is granted to the Department of Children and Families to use the photographs and slides in all aspects of Wilderness School
3
functions including slide shows, orientations and also public information materials such as newsletters, websites, brochures or
Yes
No
pamphlets and newspaper or journal articles.
I understand that the student listed below will be identified by first name only in any material available to the public. I authorize the
4
use of any such photographs or slides of me without restriction as to time, except that I retain the right to revoke this authorization at
Yes
No
any time.
Parent/Caregiver Name:
Parent/Caregiver Signature:
Date:
Referring Agent/SW Name
Referring Agent/SW Signature
Date:
WILDERNESS SCHOOL - STUDENT APPLICATION
Page 3 of 4
\
ENROLLMENT
Space will be reserved upon receipt of application materials. Families and agencies will be contacted on receipt of this information. Student acceptance will be
communicated with a Wilderness School Letter of Acceptance when enrollment requirements are met.
Session 1
Session 2
20-Day Course, Boys, age 13-17 (Th, June 28 – Tue, July 17, 2018)
20-Day Course, Girls, age 13-17 (Th., July 26 – Tue, August 14, 2018)
5-Day Course, Boys age 13-17, (Fri. June 29 –Tue. July 3, 2018)
20-Day Course, Boys age 13-17 (Th., July 26– Tue, August 14, 2018)
5-Day Course, Girls, age 13-16 (Mon. July 9 – Fri. July 13, 2018)
7-Day, Co-Ed Alumni/Leadership, age 14-18 (Fri, July 27 – Th. Aug. 2, 2018)
5-Day Course, Boys, age 13-16 (Mon. July 9 – Fri. July 13, 2018)
5-Day, Girls, age 15-19 (Mon, Aug. 6 – Fri. Aug. 10, 2018)
5-Day Boys, age 15-19, (Mon. Aug. 6 – Fri. Aug. 10, 2018)
PART III – EMERGENCY EPHINEPHRINE
As authorized by the State of CT Legislature, the Wilderness School Youth Camp Physician will provide standing orders for Wilderness School Staff to use
Epinephrine and Diphenhydramine (i.e. Benadryl) in life threatening emergency situations in wilderness settings. All staff are trained and certified in emergency
use and administration by the Wilderness School Youth Camp Physician. Medication is supplied by Wilderness School.
Medication
Dosage & Frequency
Route
Reason for medication
Parent Signature
Epinephrine
As needed in Medical
Injection
Life threatening emergency
(Epi-Pen, 0.3 mg)
Emergency
(Subcutaneous)
in a wilderness setting
Antihistamine,
As needed in Medical
Life threatening emergency
Diphenhydramine HCL,
Oral
Emergency
in a wilderness setting
25 mg caplet
PART IV – AUTHORIZATION FOR DISCLOSURE OF INFORMATION
I authorize the Wilderness School to disclose/obtain the information indicated below pertaining to :
Student Name
DOB:
To / From (List all appropriate providers, referring agents and/or individuals:
This authorization covers information files and records even though such are considered confidential by the source, i.e. schools, doctors, or hospitals and includes, but
is not limited to, juvenile or adult court records, police records, psychiatric records, medical records (including HIV-related information), and reports from the Wilderness
School.
This consent to disclose/obtain may be revoked by me by a written request at any time. This consent expires upon completion of the three-phase (Orientation,
Expedition, and Follow-up) Wilderness School program
Confidentiality of records is required by Connecticut Statutes, Chapter 320, Section 17-431. Therefore, the received information shall not be transmitted to a third party
without prior consent or other authorization as provided in the statutes.
Pursuant to Connecticut Public Act 89-246, parties to whom this information is disclosed will be informed:
This information has been disclosed to you from records whose confidentiality is protected by State Law. State law prohibits you from making any further disclosure of
it without the specific written consent of the person to whom it pertains, or as otherwise permitted by said law. A general authorization for the release of medical or
other information is not sufficient for this purpose.
Student Signature
Date:
Parent/Caregiver Signature:
Date:
WILDERNESS SCHOOL - STUDENT APPLICATION
Page 4 of 4
PART V – TUITION AGREEMENT
This agreement is between the State of Connecticut Department of Children and Families Wilderness School and the Referring Agency and/or family.
Applicant LAST Name:
Applicant FIRST Name:
Legal Guardian LAST Name :
Legal Guardian FIRST Name:
Guardian Address (No. and Street):
City:
State:
Zip:
Referring Agent LAST Name:
Referring Agent FIRST Name:
Relationship:
Referring Agency Address (No. and Street):
City:
State:
Zip:
Funding Agency, (if different from Referring Agency)
Funding Agency Contact Name:
Funding Agency Phone #:
Funding Agency Address (No. and Street):
City:
State:
Zip:
Applicant Status (please check one):
Committed-Abuse/Neglect
Committed-Delinquent
Committed-Dual
Not Committed
FWSN
Not DCF involved
DCF Prevention Services (please check one):
FWSN
Juvenile Redirection
PYDI
State of CT Judicial Branch
CSSD
Indicate source(s) of tuition below: Total = $2,000.00 for 20-day Expeditions and $600.00 for 5-day Expeditions or 7-Day Expedition
Agency Payment/Amount:
Family Payment/Amount:
Other/Amount:
DCF Tuition Payment: Any applicant that is involved with DCF (committed and non-committed) must have tuition authorized by the Area Office. DCF Social
1
Workers must sign the tuition agreement form, indicating appropriate use of agency funds.
Tuition Fee: The tuition fee of the Wilderness School 20-Day Expedition is $2,000.00. This fee includes all phases of the Orientation, 20-Day Expedition,
2
and Follow-Up Programs as detailed in the Wilderness School website. The tuition fee of all Wilderness School 5-Day and 7-Day Expeditions is $600.00. This
fee includes all phases of the Orientation, Expedition, and Follow-Up Programs as detailed in the Wilderness School website.
When to Make Payment: All tuition payments by private parties other than Referring Agencies (i.e. family payments) must be made in full after an applicant’s
3
acceptance to the Expedition and prior to the course start.
Acceptable Forms of Payment: All tuition payments by private parties other than Referring Agencies must be made with a bank check or money order
4
only. No personal checks or cash may be accepted.
How to Make Payment: Bank checks or money orders must be made payable to DCF/Wilderness School and may be sent c/o Wilderness School, 240 North
5
Hollow Road, East Hartland, CT 06027, Attn: Enrollment Office.
Refund Policies:
a)
All tuition payments will be fully refunded if cancellation occurs prior to the course starting date.
6
b)
If a student leaves a course within the first three (3) days for medical reasons, one-half of the tuition will be refunded. After three (3) days, there
will be no refund
c)
If a student leaves a course for non-medical reasons, there will be no refund.
Student Acceptance: Applicants for Expeditions are enrolled when Referring Agency staff have received a formal Letter of Acceptance from the Wilderness School
Enrollment Office stating all Application Materials are completed to a satisfactory degree, including: Receipt of a signed Tuition Agreement and payment in full ten
days prior to the beginning of the Expedition for any full or partial family payments; Acceptance of all Applications Materials by the Wilderness School.
Tuition Agreement: The Wilderness School, a program of the State of Connecticut, Department of Children & Families, will provide services as outlined on the
Wilderness School website. Wilderness School expeditions may include backpacking, hiking, rock climbing and rappelling, canoeing, a solo, a day of service, an
8.5 mile marathon, the high ropes course, problem solving tasks, group discussions, graduation ceremonies, and follow-up activities. Tuition Agreement is valid for
1 year from date.
I fully understand and will abide by the tuition policy of the Wilderness School
Name of party responsible for tuition payment:
Signature of party responsible for tuition payment:
Date:
Page of 4