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Johnsville Mennonite Church

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Medical information and releases

To complete registration, please take the time to fill out the information below.

Child's Full Name

Please list any allergies to food or medication

Does your child have any medical or special needs they are being seen by a doctor for or receiving treatment for, including medication being used? If yes, please list medical diagnosis, medications and treatments.

Family Doctor Name/ Dentist Name

Emergency Contact 1

Emergency Contact 2

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Medical information and releases

To complete registration, please take the time to fill out the information below.

Child's Full Name

Please list any allergies to food or medication

Does your child have any medical or special needs they are being seen by a doctor for or receiving treatment for, including medication being used? If yes, please list medical diagnosis, medications and treatments.

Family Doctor Name/ Dentist Name

Emergency Contact 1

Emergency Contact 2

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