Wellspring Pharmacy Registration

Camp Ramah in California 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
2025 Sessions*

Session One and Gesher Alef: June 17-July 14Gesher Bet: July 2 to July 14Session two and Gesher Gimmel: July 17 to August 12Gesher Dalet: July 31 to August 10
Parent/Guardian Information
Name*

First NameLast Name
Primary Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Email*
example@example.com
Camper's Information

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

First NameLast Name
Birth Date*

MonthDayYear
Gender*

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

Please list all medications (prescription, OTC, vitamins and supplements) that the camper is currently taking. Over-the-counter medications or vitamins 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 (Please indicate time of administration preferred) 1
Please indicate time of administration preferred

Remainder Closer
Payment Information:

Please expect a call from someone at Wellspring Pharmacy to collect your payment information.
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: