Boundless Adventures Berlin Summer Camp Medical Form 2026

  • Section I: General Information

  • Birth Date*
     - -
  • Gender*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Which week will your child be attending camp?

  • Section II: Medical Information

  • Allergies & Diet

  • Allergies*
  • Diet, Nutrition*

  • Medical Insurance Information

  • This camper is covered by family medical/hospital insurance*

  • Parent/Guardian Authorization for Healthcare:

    This health history is correct and accurately reflects the health status of the camper to whom it pertains. The person described has permission to participate in all camp activities except as noted by me and/or an examining physician. I give permission to the  Health Care Consultant selected by the camp to order x-rays, routine tests, and treatment related to the health of my child in emergency situations. If I cannot be reached in an emergency, I give my permission to the Health Care Consultant to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for this child. I understand the information on this form, and any treatment or intervention required during the conduct of camp, will be shared on a "need to know" basis with camp staff or health professionals in the conduct of official duties, such as providing medical treatment. I give permission to photocopy this form. In addition, the camp has permission to obtain a copy of my child's health record from providers who treat my child and these providers may talk with the program's staff about my child's health status.

  • Date*
     - -

  • Immunization History

    Provide the month and year for each immunization. Starred (*) immunizations must include date to meet ACA Standard. Copies of immunization forms from health-care providers or state or local government are acceptable. Please send forms to ma_info@boundlessadventures.net or upload at the end of this section.
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  • Medication

  • Medication*

  • The following non-perscription medications may be stocked in camp and are used on an as needed basis to manage illnesses and injury. 

  • Please indicate which medication should NOT be given.

  • General Health History

    Check "Yes" or "No" for each statement. Explain "Yes" answers below. Has/does the camper:
  • Ever been hospitalized?*
  • Ever had surgery?*
  • Have recurrent/chronic illnesses?*
  • Have a recent infectious disease?*
  • Had a recent injury?*
  • Had asthma/wheezing/shortness of breath?*
  • Have diabetes?*
  • Had seizures?*
  • Had headaches?*
  • Wear glasses, contacts, or protective eyewear?*
  • Had fainting or dizziness?*
  • Passed out/had chest pains during exercise?*
  • Had mononucleosis ("mono") during the past 12 months?*
  • If female, have problems with periods/menstruation?*
  • Ever have back/joint problems?*
  • Have problems with diarrhea/constipation?*
  • Have any skin problems?*
  • Traveled outside the country in the past 9 months?*

  • Mental, Emotional, and Social Health

    Has the camper:
  • Ever been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (AD/HD)?*
  • Ever been treated for emotional or behavioral difficulties or an eating disorder?*
  • During the past 12 months seen a professional to address mental/emotional health concerns?*
  • Had a significant event that continues to affect campers life? (History of abuse, death of a loved one, family change, adoption, foster care, new sibling, survived a disaster, other)*

  • Health-Care Providers

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • This camp must comply with regulations of the MDPH and be licensed by the LBOH.  Parents/guardians have the right to review Background Check, Health Care, Discipline Policies and grievance procedures upon request.  

  • Should be Empty: