Wellspring Pharmacy Registration

Camp Hess Kramer & Gindling Hilltop Camp Registration Form

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

Lev: June 25 to July 9Chav, Hal, Mitz: June 25 to July 16Hineni, Havurah, Kehillah, Leadership: July 19 to August 13Nefesh: July 19 to July 30Halutzim, Mitzvah: June 26 to July 18Teetam: July 11 to July 16Vatikim: July 19 to Aug 6CIT: June 23 to Aug 13
Parent/Guardian Information
Name*

First NameLast Name
Primary Phone Number*
Email
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
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 takes more than 10 (request a call from Wellspring Pharmacy)Not 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:

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

All information is held strictly confidential. At no given point is your credit card information disclosed or shared without your consent. NOTE: You are responsible for your camper's registration fee, co-pay and any late fees. Wellspring Pharmacy will debit all registration fee(s) at the time of registration. You will be charge for your camper's co-pays after your camper's medications are delivered.
Registration fees (please select one)

Attending up to 30 days $50Attending more than 30 days $80
NOTE: If we do not receive the registration and prescriptions at least 30 days prior to the start of session, you will be charged an additional $25.00 late fee.

If we receive prescriptions less than 10 days before the start of the camp session, an additional expedited shipping fee will be charged in addition to the late fee.

Cancellation Policy. We require 14 days cancellation notice prior to your child's session, otherwise we will charge you a $25 cancellation fee.
Card Holder Name*

First NameLast Name
Card Information*

Card NumberSecurity Code
*

Expiration Date Postal 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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