2026 Surprise Lake Camp Pharmacy Form-Part 1

2026 Surprise Lake Camp Pharmacy Form-Part 1
INSTRUCTIONS - PART 1 OF 2

Welcome! We’re excited to support your child during their time at Surprise Lake Camp this summer.

This registration process is completed in two parts and must be finished in full for your camper to be considered registered with Drug World's Camp Medication Program.

Once this form is submitted, you will be automatically redirected to Part 2.

WHAT YOU'RE COMPLETING NOW (Part 1):
- Parent/guardian contact details
- Camper health information (including allergies and medical notes)
- Physician and home pharmacy information
- Insurance details
- $2 registration fee
For the 2026 season, registration will include a $2 processing fee.

While the camp continues to cover the cost of medication packaging and coordination, this nominal fee allows the pharmacy to securely establish and maintain each camper’s account, streamline communication, and respond quickly to any medication-related needs, helping ensure safe, timely, and accurate medication management for every camper.

PRESCRIPTION DELIVERY OPTIONS (Doctor-Submitted):

1. E-Prescribe (preferred)
Your child’s physician may electronically submit prescriptions directly to:

Drug World of Cold Spring, LLC
55 Chestnut Street
Cold Spring, NY 10516
Phone: 845-265-6352

2. Paper Prescriptions (if necessary)
Mailed to the address above
Attn: Caitlin Chadwick

Parents are responsible for ensuring prescriptions are sent on time.

IMPORTANT REMINDER
Your camper’s registration is not complete until both Part 1 and Part 2 are submitted AND we have received the required prescriptions from your child’s physician.

Please arrange for timely delivery of prescriptions to avoid delays. For a more detailed overview of our process, you can download our Family Infographic and review additional FAQs on our webpage linked here.

PAYMENT INFORMATION
The $2 registration fee is collected here.
Any future co-pays or medication-related charges will be billed separately.

Co-pay payments are processed via NIMBLE, our secure payment system.

If you have any questions, please email us at camp@drugworld.com or contact Caitlin Chadwick at 845-265-6352 ext. 129.

Thank you for your cooperation!

Warm regards,
The Drug World Team

2026 Surprise Lake Camp Pharmacy Form- Part 2
Camper's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
CAMPER'S GENDER IDENTITY*
CAMPER'S GENDER (for insurance purposes only)*
Parent/Guardian Name*

First NameLast Name
My child will be attending Surprise Lake Camp for:*

Full Summer (6/28 - 8/23)Session One (6/28 - 8/2)Session Two (8/4 - 8/23)Mini Camp (7/14 - 8/2)Get your Feet Wet (8/26 - 8/30)
Email*
example@example.com
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number*
Please enter a valid phone number.
Does your Child have any allergies?*

YesNo
List Allergies Here
PRESCRIBING PHYSICIAN
Physician's Name

First NameLast Name
Physician's Phone Number
Please enter a valid phone number.
Physician's Fax Number
Please enter a valid phone number.
Physician's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
SECONDARY PHYSICIAN INFORMATION
Physician Name

First NameLast Name
Physician Phone
Please enter a valid phone number.
Physician Fax
Please enter a valid phone number.
Physician Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
HOME PHARMACY
Home Pharmacy Name
Home Pharmacy Phone Number
Please enter a valid phone number.
Home Pharmacy Fax Number
Please enter a valid phone number.
Home Pharmacy Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
INSURANCE INFORMATION
Pharmacy Insurance Carrier
Member ID #
RX Group #
RXPCN #
RXBIN #
Primary Subscriber's Name

First NameLast Name
Camper's relationship to Subscriber
Front Prescription Insurance Card

Cancelof
Back of Prescription Insurance Card

Cancelof
Front of Prescription Card
Back of Prescription Card
NEW PHARMACY FEE: There is a $2.00 Pharmacy registration fee for all completed Pharmacy Forms received by June 5, 2026. A Pharmacy Form is considered complete once both Part 1 and Part 2 are fully filled out and all required prescriptions have been received by the Pharmacy.

A late fee of $100.00 will be assessed for all Pharmacy Forms received on or after June 5, 2026.

It is imperative that all prescriptions are received by the Pharmacy by the applicable deadline. Any prescription received after June 5, 2026 may result in delayed delivery and may not be available when camp begins.

For second-session campers only: Pharmacy Forms received after July 10, 2026 will incur a $100.00 late fee.

RELEASE OF INFORMATION (Title 42 CFR): The Undersigned hereby permits Drug World Pharmacy and its workforce, to disclose the patient's personally identifiable information for purposes related to the patient's treatment, to obtain payment for the patient's treatment and in the other circumstances where federal law does not require my further Authorization. The Undersigned also grants permission to release medical information to other health care providers involved in the patient's care and to others involved in planning for the care of the patient. The Undersigned likewise grants permission for these parties to release appropriate information back to Drug World Pharmacy. This consent is subject to revocation at any time except to the extent that Drug World has already taken action in reliance on it. If not previously revoked, this consent will terminate six (6) months from last invoice for pharmacy service.

ASSIGNMENT OF BENEFITS: The Undersigned hereby certifies that all insurance information reported to Drug World includes all available sources of coverage, and assigns to Drug World, payment from said insurance to pay for the patient's prescription needs.

FOR PATIENTS ENTITLED TO MEDICARE BENEFITS: If applicable, the Undersigned hereby certifies that the information provided in applying for payment under Title XVIII of the Social Security Act is correct. The Undersigned authorizes Drug World to release to the Social Security Administration and Centers for Medicare and Medicaid Services (CMS) or its intermediaries or carriers, any information needed for this or a related Medicare claim. The Undersigned also requests that payments of authorized benefits are made on the patient's behalf. The Undersigned assigns benefits payable for pharmacy services to Drug World and authorizes Drug World to submit a claim to Medicare for payment.

FOR CO-PAYS AND FEES NOT COVERED BY MY INSURANCE: I authorize the Pharmacy to contact the insurance company to verify insurance coverage for the Child. I acknowledge responsibility for the cost of any medication not covered by my insurance company, for any medication denied reimbursement, as well as any co-payments, deductibles, and over-the-counter items I order, which I agree will be billed directly to my credit card by the Pharmacy. I authorize Drug World to charge the credit card indicated in this authorization form, and I certify that I am an authorized user of this credit card.
PLEASE SIGN THE FOLLOWING
I authorize the pharmacy to contact the Insurance company for insurance verification.*

Clear
I authorize the pharmacy to bill my credit card directly. *

Clear
I acknowledge responsibility for the cost of any medication not covered by my insurance company, for any medication denied reimbursement, as well as any co-payments and deductibles, which I agree will be billed directly to my credit card by the Pharmacy.*

Clear
Signature of Guarantor: I acknowledge that all insurance information I have provided is accurate.*

Clear

Camper Registration*

Camper Registration

$2.00 Quantity

Enter coupon

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Should be Empty:

2026 Surprise Lake Camp Pharmacy Form-Part 1

2026 Surprise Lake Camp Pharmacy Form- Part 2

PRESCRIBING PHYSICIAN

SECONDARY PHYSICIAN INFORMATION

HOME PHARMACY

INSURANCE INFORMATION

PLEASE SIGN THE FOLLOWING