Boundless Adventures Berlin Summer Camp Medical Form 2025

Section I: General Information
Camper's Information:*

First NameLast Name
Birth Date*

MonthDayYear
Date
Camper's Home Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Gender*

MaleFemalePrefer Not To SayOther
Parent/legal guardian to be contacted in case of illness or injury*

First NameLast Name
Relationship to Camper*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Second parent/legal guardian or other emergency contact

First NameLast Name
Relationship to Camper
Phone Number
Please enter a valid phone number.
Email
example@example.com
Additional contact (carpool or other emergency contact)

First NameLast Name
Relationship to Camper
Phone Number
Please enter a valid phone number.
Email
example@example.com

Which week will your child be attending camp?

June 23-29July 7-11July 14-18July 21-25July 28-Aug 1August 4-8August 11-15
Section II: Medical Information
Allergies & Diet
Allergies*

FoodMedicineEnvironmentOtherNo known allergies
Please describe below what the camper is allergic to and the reaction seen
Diet, Nutrition*

This camper eats a regular diet.This camper eats a regular vegetarian diet.This camper is lactose intolerant.This camper is gluten intolerant.
Please provide additional information about diet and nutrition
Medical Insurance Information
This camper is covered by family medical/hospital insurance*

YesNo
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.
Signature of Custodial Parent/Guardain*

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Date*

MonthDayYear
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.
Tuberculosis (TB) test Date:
Tuberculosis (TB) test Result
Medical & Immunization Record Upload

Cancelof
Medication
Medication*

This camper will not take any daily medications while attending camp.This camper will take the following daily medication(s) while at camp.
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.

Acetaminophen (Tylenol)Phenylephrine decongestant (Sudafed PE)Antihistamine/allergy medicineDiphenhydramine antihistamine/allergy medicine (Benadryl)Sore throat sprayCalamine lotionIbuprofen (Advil, Motrin)Pseudoephedrine decongestant (Sudafed)Guaifenesin cough syrup (Robitussin)Dextromethorphan cough syrup (Robitussin DM)Antibiotic creamAloeBismuth subsalicylate for diarrhea (Kaopectate, Pepto-Bismol)
General Health History

Check "Yes" or "No" for each statement. Explain "Yes" answers below. Has/does the camper:
Ever been hospitalized?*

YesNo
Ever had surgery?*

YesNo
Have recurrent/chronic illnesses?*

YesNo
Have a recent infectious disease?*

YesNo
Had a recent injury?*

YesNo
Had asthma/wheezing/shortness of breath?*

YesNo
Have diabetes?*

YesNo
Had seizures?*

YesNo
Had headaches?*

YesNo
Wear glasses, contacts, or protective eyewear?*

YesNo
Had fainting or dizziness?*

YesNo
Passed out/had chest pains during exercise?*

YesNo
Had mononucleosis ("mono") during the past 12 months?*

YesNo
If female, have problems with periods/menstruation?*

YesNo
Ever have back/joint problems?*

YesNo
Have problems with diarrhea/constipation?*

YesNo
Have any skin problems?*

YesNo
Traveled outside the country in the past 9 months?*

YesNo
Please explain "Yes" answers in the space below. For travel outside of the country, please name countries visited and dates of travel.
Mental, Emotional, and Social Health

Has the camper:
Ever been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (AD/HD)?*

YesNo
Ever been treated for emotional or behavioral difficulties or an eating disorder?*

YesNo
During the past 12 months seen a professional to address mental/emotional health concerns?*

YesNo
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)*

YesNo
Please explain "Yes" answers in the space below.
Health-Care Providers
Camper's Primary Doctor(s)*

First NameLast Name
Doctor's Phone Number
Please enter a valid phone number.
Camper's Dentist

First NameLast Name
Dentist's Phone NUmber
Please enter a valid phone number.
What have we forgotten to ask? Please provide in the space below any additional information about the camper's health that you think important or that may affect the camper's ability to fully participate in the camp program. Additionally, if you have any specific requests for your child to be grouped with certain kids, you can include that information here as well.
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:

Section I: General Information

Section II: Medical Information

Allergies & Diet

Medical Insurance Information

Immunization History

Medication

General Health History

Mental, Emotional, and Social Health

Health-Care Providers