Camp Eden Village West

Eden Village West

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

Important: You will need to send your child's physician instructions on how to prescribe for camp sessions. Click here for Physician Instructions
Your Child's Camp Session(s) (check all that apply)*

Session 1: June 19 to July 7Session 2: July 10 to July 28Session 1A: June 19 to June 30Session 2A: July 10 to July 21Six Weeks Journey: June 19 to July 28
Parent/Guardian Information
Name*

First NameMiddle NameLast Name
Primary Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Email*
example@example.com
Camper's Information

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 number
Camper's Medication

***PLEASE NOTE: BEGINNING 2023, Camp Alonim will not be accepting vitamins, homeopathic and herbal supplements, and melatonin without a prescription or an official doctor’s note. Have your doctor sends the prescription for such items to Wellspring Pharmacy to be filled for camp. ALL CONTROLLED PRESCRIPTIONS MUST BE SENT BY YOUR CAMPERS PHYSICIAN.
Drug Allergies?*

YesNo
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:

Remainder Closer
Payment Information

All information is held strictly confidential. At no given point is your credit card information disclosed or shared without your consent. NOTE: You are responsible for your camper's registration fee, co-pay and any late fees. Registration fee(s) are due at the time of registration. You will be charge for your camper's co-pays after medications are sent. INCOMPLETE PAYMENT INFORMATIONS WILL RESULT IN INCOMPLETE REGISTRATION)

My Products

Attending up to 30 days $50.00

Attending more than 30 days$80.00

Total $0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

NOTE: If we do not receive the registration and prescriptions at least 21 days prior to the start of session, you will be charged an additional $25.00 late fee. If we receive prescriptions less than 10 days before the start of the camp session, an additional expedited shipping fee will be charged in addition to the late fee.

Cancellation Policy. We require 14 days cancellation notice prior to your child's session, otherwise we will charge you a $35 cancellation fee.
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:

Eden Village West

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