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 Page 1
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 Page 2