Camper's Prescription Information

Campers Prescription Information
We are asking that prescriptions be sent directly from your campers provider to our pharmacy, and only for the total number of days they will be attending camp. Please be aware that we are only able to pack oral tablets/capsules, and any liquid, topical, or other medications should be provided directly to Camp Friendship. Prescriptions are required at least 2 weeks in advance of camp arrival date.
First
Middle
Last
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Gender
Allergies
Last Four Digits of Social Security # for insurance purposes
Dates attending Camp Friendship: from:
from
to
Parent or Guardian Contact Info
Name
Relationship
Phone
Format: (000) 000-0000.
Name
Relationship
Phone
Format: (000) 000-0000.
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If you would prefer to provide payment information over the phone, please call us at 434-589-7902 after completing the remainder of this form.
Please contact us at 434-589-7902 to provide payment information after completing this form. Payment will be processed approximately 1-2 weeks prior to your campers arrival.
Cardholder Name
Credit Card #
Expiration Date
Security Code (3 digits on back of card)
Copy of Prescription Insurance Card

Cancelof
Copy of Parent or Guardian Driver's License

Cancelof
Camper Name
DOB

MonthDayYear
Date
Please list all the medications that should be placed in blister packs- please be aware that we are limited to dispensing only oral tablets and capsules this way. For any other types of medication, please reach out to Camp Friendship directly to see how that is best handled.
1) Medication Name
1) Medication Strength
1) Dosing Frequency
1) Times of Day
2) Medication Name
2) Medication Strength
2) Dosing Frequency
2) Times of Day
3) Medication Name
3) Medication Strength
3) Dosing Frequency
3) Times of Day
4) Medication Name
4) Medication Strength
4) Dosing Frequency
4) Times of Day
5) Medication Name
5) Medication Strength
5) Dosing Frequency
5) Times of Day
6) Medication Name
6) Medication Strength
6) Dosing Frequency
6) Times of Day
7) Medication Name
7) Medication Strength
7) Dosing Frequency
7) Times of Day
8) Medication Name
8) Medication Strength
8) Dosing Frequency
8) Times of Day
9) Medication Name
9) Medication Strength
9) Dosing Frequency
9) Times of Day
10) Medication Name
10) Medication Strength
10) Dosing Frequency
10) Times of Day
Additional information you would like us to know:
Should be Empty:

Campers Prescription Information

Jotform uses end-to-end encryption to ensure that your information stays secure.

Please contact us at 434-589-7902 to provide payment information after completing this form. Payment will be processed approximately 1-2 weeks prior to your campers arrival.