Wellspring Pharmacy Registration

Camp Mountain Chai

provided by Wellspring Pharmacy, Oakland CA
Please read our Camp's Term of Use & FAQ prior to completing this form.

*Please note: You will need to send your child's physician instructions on how to prescribe for camp sessions.

Click here for Physician Instructions
Sessions (check all that apply)*

Session 1: June 17 – June 30SIT: June 17 – July 21Kavanah: June 17 – July 11Rishonim A: June 24– June 30Session 2: July 2 – July 21Session 3: July 23 – August 5Rishonim B: July 23 – July 28Rishonim C: July 30 – August 5
Parent/Guardian Information
Name *

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Primary Phone Number *

Area CodePhone Number
Email*
example@example.com
Camper's Information

Please complete a separate form for each camper
Camper's Name*

First NameLast Name
Birth Date*

MonthDayYear
Gender*

MaleFemaleN/A
Prescription Insurance Information

Upload a photo of your camper's pharmacy insurance card
Front of card

Browse Files

Cancelof
Back of card

Browse Files

Cancelof
Help desk telephone number

Area CodePhone Number
Camper's Medication

Please list all medications (prescription, OTC, vitamins and supplements) that the camper is currently taking. Over-the-counter medications or vitamins do not require a prescription. Please contact us if there are medication changes as we approach camp season.
Drug Allergies?*

YesNo
List all drug allergies:
How many Medications does your child require?
If more than ten, please check the option for a consultation under the "Medication #10" section
Medication #1
Medication Name

NameStrength
FormQuantity
Directions:
Example: Take 1 tablet orally every day
Time

:HourMinutesAM/PM Option
Special instructions (Please indicate time of administration preferred)
Please indicate time of administration preferred

Add Medication #2
Medication #2
Medication Name

NameStrength
FormQuantity
Directions:
Example: Take 1 tablet orally every day
Time

:HourMinutesAM/PM Option
Special instructions:

Add Medication #3
Medication #3
Medication Name

NameStrength
FormQuantity
Directions:
Example: Take 1 tablet orally every day
Time

:HourMinutesAM/PM Option
Special instructions:

Add Medication #4
Medication #4
Medication Name

NameStrength
FormQuantity
Directions:
Example: Take 1 tablet orally every day
Time

:HourMinutesAM/PM Option
Special instructions:

Add Medication #5
Medication #5
Medication Name

NameStrength
FormQuantity
Directions:
Example: Take 1 tablet orally every day
Time

:HourMinutesAM/PM Option
Special instructions:

Add Medication #6
Medication #6
Medication Name

NameStrength
FormQuantity
Directions:
Example: Take 1 tablet orally every day
Time

:HourMinutesAM/PM Option
Special instructions:

Add Medication #7
Medication #7
Medication Name

NameStrength
FormQuantity
Directions:
Example: Take 1 tablet orally every day
Time

:HourMinutesAM/PM Option
Special instructions:

Add Medication #8
Medication #8
Name:
FormQuantity
Directions:
Example: Take 1 tablet orally every day
Time

:HourMinutesAM/PM Option
Special instructions:

Add Medication #9
Medication #9
Medication name:
FormQuantity
Directions:
Example: Take 1 tablet orally every day
Time

:HourMinutesAM/PM Option
Special instructions:

Add Medication #10
Medication #10
Medication name:
FormQuantity
Directions:
Example: Take 1 tablet orally every day
Time

:HourMinutesAM/PM Option
Special instructions:

Remainder Closer
Payment Information:

Please expect a call from someone at Wellspring Pharmacy to collect your payment information.
By signing, you agree to Wellspring Pharmacy's, Summer Camp Meds Terms of Use & Privacy Policy Agreement.*

Clear
BY SIGNING ABOVE, I ACKNOWLEDGE THAT THE SIGNATURE WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Should be Empty:

Camp Mountain Chai

Parent/Guardian Information

Camper's Information

Prescription Insurance Information

Camper's Medication

Medication #1

Medication #2

Medication #3

Medication #4

Medication #5

Medication #6

Medication #7

Medication #8

Medication #9

Medication #10

Payment Information: