Registration-Emergency Medical Form

Registration/Emergency Medical Form
Personal Information
Child's Name _____________________________________________________________________________
Last

First

Middle

Address ____________________________________ City _________________ State _______ Zip _______
Home Phone ________________________________________ Birth Date ___________________________
School Grade _____________ School Name (Public/Private/Home) ______________________________
Please Circle One

Siblings' Names and Ages
Name ______________________ Age ___________ Name ______________________ Age ___________
Name ______________________ Age ___________ Name ______________________ Age ___________
Name ______________________ Age ___________ Name ______________________ Age ___________
Child's Strengths/Areas of Interest:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Church Affiliation _________________________________________________________________________

Parental Information
Mother's Name ____________________________________________________________________________
Last

First

Middle

□ (Check Here if Address is Same as Child's) Email _____________________________________________
Address ____________________________________ City _________________ State _______ Zip ________
Home Phone _________________ Work Phone _________________ Cell Phone _____________________
Father's Name ____________________________________________________________________________
Last

First

Middle

□ (Check Here if Address is Same as Child's) Email _____________________________________________
Address ____________________________________ City _________________ State _______ Zip ________
Home Phone _________________ Work Phone _________________ Cell Phone _____________________
Emergency contact in the event parents/guardians cannot be reached:
Name ___________________________________________ Relationship ____________________________
Last

First

Home Phone _________________ Work Phone _________________ Cell Phone _____________________
Capital City Church Assembly of God, 1290 Old Henderson, Columbus, OH 43220, 614.442.1700
www.capitalcitychurch.org
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Registration/Emergency Medical Form
Part 1 or Part 2 Must Be Completed Below
Part 1: To Grant Consent
I hereby give my consent for the following physician, medical professionals, and hospitals to provide
services to my child:
Physician’s Name _____________________________________ Phone ______________________________
Dentist’s Name _______________________________________ Phone ______________________________
Hospital’s Name ______________________________________ Phone ______________________________
In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for
1) the administration of any treatment deemed necessary by the above named specialists or in the
event the designated professional is not available by another physician or dentist and 2) the transfer of
the child to the emergency facilities.
This authorization does not cover major surgery unless the medical opinions of two other licensed
physicians or dentists concurring in the necessity of such surgery are obtained prior to the performance
of such surgery.
**Medical history, allergies, current medication, and any physical impairment to which physicians
should be alerted:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Parent/Guardian Signature
Date

Part 2: Refusal To Consent
I do not give my consent for emergency treatment of my child. In the event of an emergency, I wish
the church to take the following action(s):
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Parent/Guardian Signature
Date

Capital City Church Assembly of God, 1290 Old Henderson, Columbus, OH 43220, 614.442.1700
www.capitalcitychurch.org
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