Medical Release Form | EWoW Community Site

Medical Release From

Student Information

Student Name

Student Date of Birth required

Main Contact Information (Parent/Guardian)

Parent/Guardian Name

Parent/Guardian Best Phone Number

Emergency Contact Information (Non - Parent/Guardian)

Emergency Contact Name

Emergency Contact Best Phone Number

Medical Information

Physician Name

Psysician Phone Number

Name of the insurance company issuing medical care & hospitalization coverage.

Policy/Certificate #

Education without Walls requires a copy of the student's insurance card to be delivered before the first day of classes. Please indicate how you plan to deliver this information.

A hard copy of my child's insurance card will be mailed/delivered to 65 Bridge Street.

A copy of my child insurance card will be uploaded in this form.

Upload an image of your child's insurance card here.

Upload File

Upload supported file (Max 15MB)

Education without Walls requires an up to date copy of the student’s vaccination records OR a document explaining your child's need for a medical and/or religious exemption, in accordance with Connecticut State Law, to be delivered before the first day of classes. The State of Connecticut requires immunization against diphtheria, pertussis, tetanus, poliomyelitis, measles, mumps, rubella, and homophilus influenza type B.

Please Indicate how you plan to deliver this information.

A hard copy of the requested document will be mailed/delivered to 65 Bridge Street.

A digital copy of the requested document will be uploaded in this form.

Upload a copy of the requested document here.

Upload File

Upload supported file (Max 15MB)

List and describe any illness or condition for which your child is now under treatment, any disability, medications your child is currently taking, medicines to which your child is allergic, and any other allergies your child has (insect bites, etc.).

Important Information

I understand that my child will be taken, by ambulance if necessary, to New Milford Hospital in the case of an emergency.‎*

I understand that, in an emergency, parents/guardians, then emergency contacts, will be contacted as quickly as possible.*

Permission is hereby granted for emergency medical treatment as needed by:

Parent/Guardian Signature

Date required

Thanks for submitting!