Wellspring Pharmacy Registration

Camp Ramah Registration Form

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

Session One, Gesher Aleph & Bet : June 15, 2023 to July 10, 2023Session Two, Gesher Gimel & Dalet : July 13, 2023 to August 8, 2023
Parent/Guardian Information
Name*

First NameLast Name
Primary Phone Number*

Area CodePhone Number
Email
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Camper's Information

If more than one child is attending camp, please complete a separate form for each camper. If you have any questions, call us at 510-428-1559.
Camper's Name*

Camper's First NameCamper's Last Name
Birth Date*

MonthDayYear
Gender*

MaleFemale
Drug Allergies?

YesNo
List all drug allergies:
Chronic Illness?

YesNo
List all chronic illnesses:
Prescription Insurance Information
Insurance name:*
RX BINRX PCN
Member ID:*
RX Group:*
Pharmacy help desk telephone number

Area CodePhone Number
Camper's Medication

Please list all medications (prescription, OTC, vitamins and supplements) that the camper is currently prescribed or is taking. Over-the-counter medications or vitamins do not require a prescription from your camper's physicians. Make sure you review your camper's Rx with your physician to confirm it is written exactly the way your camper takes the medication before sending to Wellspring Pharmacy. Please contact us if there are medication changes as we approach camp season. ALL CONTROLLED PRESCRIPTIONS MUST BE SENT BY YOUR CAMPERS PHYSICIAN.
Need more than 10 Prescription?

My child take more than 10 (request a call from Wellspring PharmacyNot applicable
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 (Please indicate time of administration preferred)
Please indicate time of administration preferred

Remainder Closer
Physician Information:
Physician's Name

First NameLast Name
Contact Info

Phone NumberFax Number
Physician's Email
example@example.com
Other Physician Information
Additional Physician, Psychiatrist, etc
Payment Information:

Camp Ramah is paying the Wellspring registration fee this year. Wellspring Pharmacy will only charge you the co-pay for your co-pay(s) and potential late fes. Camp Ramah will continue to charge a Medication Administration Fee per the parent handbook. All information is held strictly confidential. At no given point is your credit card information disclosed or shared without your consent.
Name*

First NameLast Name
Card information*

Credit Card NumberSecurity Code
*

Expiration DatePostal Code
By signing, you agree to Wellspring Pharmacy's, Summer Camp Meds Terms of Use & Privacy Policy Agreement.*

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. Clear
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