good life girls

Medical History Form

This form must be dated after May 1st, 2019 and then be submitted before your child attends our programs. This form must be completely filled out and any medications that your child is using must accompany a signed letter of use and dosage from your child’s primary physician.

All participants are required to be compliant with Colorado’s Department of Health and Human Services Vaccines Required for Child Care and K-12 Education Services.  Failure to be in compliance may be a reason to deny children from participating in this program.

These records will remain strictly confidential between parents and supervisors of Good Life Girls, only allowing access to the supervisors of Good Life Girls.

THANK YOU FOR JOINING THE GOOD LIFE GIRLS!

Child's Information
Child's Name *
Child's Name
Child's Birthday *
Child's Birthday
Phone Number of Child's Primary Physician
Phone Number of Child's Primary Physician
Address of Child's Primary Physician
Address of Child's Primary Physician
Name of Child's Primary Dentist
Name of Child's Primary Dentist
Phone Number of Child's Primary Dentist
Phone Number of Child's Primary Dentist
Address of Child's Primary Dentist
Address of Child's Primary Dentist
In Case of Emergency
Name of Primary Insured
Name of Primary Insured
Does the Primary Insured have Medicaid? *
Does the Primary Insured have Medicare? *
Activities Participating In *
Participant Medical History
Are there any injuries requiring medical attention? *
Are there any past surgeries or scheduled surgeries?
Is there any history of concussions and/or head injuries?
Is the participant currently under the care of a medical practitioner? *
Is the participant currently taking any medications? *
Does the participant have any allergies? (penicillin, bee stings, etc.)? *
Does the participant have asthma/require the use of an inhaler? *
Is the participant diabetic/require medication for diabetes? *
Does the participant carry sickle cell trait/suffer from sickle cell disease? *
Does/has the participant have/had seizures? *
Does the participant wear glasses or contact lenses? *
Does the participant wear a brace or other medical support devices? *
Does the participant have any other medical conditions? *
Please Provide Name of Medication, Dosage & Frequency, Prescribing Physician and Thier Phone Number.
Does your child carry an Epi-Pen?
If yes, please provide additional documentation by the first day of programming. This can be e-mailed to info@goodlifegirls.com or presented in person.
Does your child carry an Inhaler?
If yes, please provide additional documentation by the first day of programming. This can be e-mailed to info@goodlifegirls.com or presented in person.
Immunization History
Please indicate below whether or not your child is immunized with the following required vaccines. If your child is not immunized, you must submit a medical or non-medical exemption letter which complies with the State of Colorado’s Department of Health’s regulations.
DTaP or DTP *
Date of Last Immunization *
Date of Last Immunization
IPV *
Date of Last Immunization *
Date of Last Immunization
MMR *
Date of Last Immunization *
Date of Last Immunization
Hib *
Date of Last Immunization *
Date of Last Immunization
Hep B *
Date of Last Immunization *
Date of Last Immunization
Varicella *
Date of Last Immunization *
Date of Last Immunization
Pneumococcal *
Date of Last Immunization *
Date of Last Immunization
Agree to Terms & Signature
Agree to Terms *
I hereby certify that this information is accurate to the best of my knowledge. I understand that this medical authorization may be voided in the event of injury, illness, or accident and my child may not be cleared for participation at such time. Furthermore, I hereby acknowledge that this is my responsibility to inform Good Life Girls in writing if there is any change in the medical condition of my child. I also understand that it’s my responsibility to obtain written permission from my child’s physician on official medical stationary in order to seek permission for my child to resume participation after any and all such injury, illness, or accident.
Authorization to Obtain Emergency Medical Care *
I hereby give my permission to camp officials to contact a doctor or emergency medical services on behalf of my child and for a doctor, hospital or medical service to provide emergency medical or surgical care for my child. Should an emergency arise, it is understood that camp officials will make a conscientious effort to locate the emergency contacts listed before any action is taken. If it is not possible to locate the contacts, I will accept the expense of emergency medical or surgical treatment required to treat my child.
Please type your full name as a signature stating that you fully understand and accept all the above information presented to you and that you have filled out all the above information to the best of your knowledge.