Medical Form

Sunshine Acres Camp and Conference Center

Young Peoples Baptist Union of Brooklyn and Long Island

PO Box 1903 Seaford NY 11783

Medical Form

(To Be Completed By Parent or Guardian) 17 yrs and under
Full Name _______________________ ________________________ _______

(First) (Last) (Initial)

Home Address: _______________________________________ Apt. #: __________
City: __________________________ State: _______ Zip: ________________
Date of Birth: _______________ Age: ______ Male Female
Name of Parent/Guardian: ______________________________ Home Phone: _______________________
Work Phone: _______________________ Other Emergency Number: ________________________________
List two other people to be notified if you cannot be reached in case of an emergency. (Please include name, address and phone number)

1. 
   ___________________________________________________________________________________
   
2. 
   ___________________________________________________________________________________
   

Health History Allergies Diseases

Yes No Yes No Yes No

Convulsions ____ ____ Hay Fever ____ ____ Chicken Pox ____ ____

Diabetes ____ ____ Asthma ____ ____ Rubella ____ ____

Bedwetting ____ ____ Poison ____ ____ Rubella ____ ____

Sleepwalking ____ ____ Insect Bites ____ ____ Mumps ____ ____

Heart Problems ____ ____ Penicillin ____ ____ Pneumonia ____ ____

Kidney Problems ____ ____ Other Drugs ____ ____ (If yes, give month and year in

Rheumatic Problems ____ ____ Foods (LIST) ____ ____ space below)

(If yes, explain and give dates in space below)

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Operations or Serious Injuries: ___________________________________________ Date: ________________

Chronic or recurring illness: ___________________________________________________________________

Is there any special information regarding this person’s health, which the camp staff should know to help us in the caring for them: ______________________________________________________________________

__________________________________________________________________________________________

New York State law requires dates of the following immunizations: (Complete if under age 18)

Measles: _________________ Mumps: __________________ Rubella: __________________

Polio: 1____________ 2____________ 3_____________ 4_____________

Diph-tetanus: 1____________ 2____________ 3_____________ 4_____________

If possible, please attach a copy of this camper’s immunization record.

Medical Insurance Information: This person is covered by medical insurance: Yes No

Name of Person carrying insurance: _________________________________ Soc. Sec. #: _________________

Carrier Birth Date: ____________ Name of Insurance Company: _____________________________________ ID#: _______________________ Group Number: ______________________________

Please attach a copy of both the front and back of this person’s medical insurance card

To my knowledge there are no physical ailments which would prevent the above named person from taking part in all the activities, including athletics and sports, at Sunshine Acres. You have my permission to authorize treatment or an operation on this person in an emergency at Ellenville or Benedictine Hospitals.

Dates at camp: ____________________________________

Parent Signature: __________________________________________ Today’s Date: __________________