Metro Consultants Afterschool Enrichment Program Emergency and Health Form
(A parent or guardian must complete this form.)
This form must be completed and signed by a parent or guardian and returned prior to the first day of the
program. Please complete and return to: Metro Consultants LLC, 613 Arbor Dr, Duluth ,GA 30096
Student’s Name: Last___________________________ First___________________ Middle Initial__________
Address________________________________City____________________State______ Zip Code_________
Student’s Birth Date___/___/________ Gender__M/F_____ Blood Type___________
Does the student have any health conditions (i.e. allergies, chronic conditions) or special circumstances (i.e.
religious convictions or legal arrangements) that we ought to know about prior to emergency treatment?
[ ] NO [ ] YES
If yes, please explain, including any current medication(s):
Name and office telephone number of student’s physician:
Name of student’s health/accident insurance carrier(s) and appropriate policy information:
Carrier Policy Number
Carrier Policy Number
Parent/Guardian information:
Name____________________________ Relationship_________________Phone#___________________
Name____________________________ Relationship_________________Phone#___________________
Signature__________________________ Date__________________
If parent/guardian will be unavailable anytime during the program, please provide the information of a
responsible adult who we can contact in an emergency:
Name____________________________ Relationship___________________
Address________________________________City____________________State______ Zip Code__________
Day Phone Number______________________ Evening Phone Number________________________