Registration-emergency Medical Form

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

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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

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

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□ (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

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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