Camper Registration
Welcome to Medication Packaging for Camps!
Camper Information
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Drug Allergies?
*
No
Yes
Parent/Gaurdian Name
First Name
Last Name
Parent/Gaurdian Phone Number
*
Parent/Gaurdian E-mail
*
example@example.com
List drug allergies here
*
Prescription Insurance Provider
*
Prescription Insurance ID #
*
Rx Group #
*
Rx PCN #
*
Drivers License Number
*
Picture of Pharmacy Insurance Card (front and back)
*
Browse Files
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Camp Information
Camp Name
Camp Session Start Date
-
Month
-
Day
Year
Date
Camp Session End Date
-
Month
-
Day
Year
Date
Prescription and OTC Information
Please indicate all medications including over the counter that your child will need while at summer camp. Please note we do not supply gummies, Accutane, birth control, growth hormone or refrigerated products. Generic medications will be sent unless the DAW (dispense as written) box is checked.
*
Prescriber Information
Balance Due
Prefilled Payment Link
Prescriber's Name
*
First Name
Last Name
Prescriber's Phone Number
*
Please enter a valid phone number.
Submit
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