URJ Camp Newman

URJ Camp Newman

provided by Wellspring Pharmacy, Oakland CA
Please read our Camp Term of Use & FAQ's 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
Your Summer Camper's Session (check all that apply)*

Avodah and CIT: June 8 to August 3Shomrim, Rishonim, Hagigah:June 10 to July 6Etzim, Maccabiah, Hevrah :July 8 to August 3June 10-22:Aleph Bonim, Giborim, Tzofim, and AlufimJune 24-July 6:Bet Bonim, Giborim, Tzofim, and AlufimJuly 8-20:Gimmel Bonim, Giborim, Tzofim, and AlufimJuly 22-August 3:Daled Bonim, Giborim, and Tzofim
Parent/Guardian Information
Name*

First NameLast Name
Primary Phone Number*
Address*

Street Address

Street Address Line 2

CityState / Province

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

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

First NameLast Name
Birth Date*

MonthDayYear
Sex*

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

List all medications (prescription, OTC, vitamins and supplements) your camper is taking. Over-the-counter medications 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 1

NameStrength
Medication Form 1
Directions 1:
Example: Take 1 tablet orally every day
Time of Administration (select up to four) 1

MorningNoonEveningBedtimeAs Needed
Special instructions 1:

Remainder Closer
Payment Information

All information is held strictly confidential. You are responsible for your camper's registration fee, co-pays, 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

Your camper is attending a 4-week session

Attending more than 30 days $80.00

Your camper is attending Avodah or CIT.

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

If we do not receive the registration, prescriptions, payment(we will contact you for confirmation before completion) information 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:

URJ Camp Newman

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