Académique Documents
Professionnel Documents
Culture Documents
Personal Information
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Parental Information
Mother's Name ____________________________________________________________________________
Last First Middle
□ (Check Here if Address is Same as Child's) Email _____________________________________________
Capital City Church Assembly of God, 1290 Old Henderson, Columbus, OH 43220, 614.442.1700
www.capitalcitychurch.org Page 1
Registration/Emergency Medical Form
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:
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Parent/Guardian Signature Date
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Parent/Guardian Signature Date
Capital City Church Assembly of God, 1290 Old Henderson, Columbus, OH 43220, 614.442.1700
www.capitalcitychurch.org Page 2