* Required Information

The parent or guardian of the child is expected to get in contact with their physician to facilitate a prescription for each and every medication to be packaged and provided to camp, *including* over the counter medications. We cannot package any medication without the accompanying prescription.

Complete the form below to enroll your camper or counselor in the medication blister pack program. One enrollment per camper or counselor registered and confirmed to attend Camp.

The parents of the children attending camp can begin filling out paperwork today!

I enroll the camper / counselor list above in the medication blister pack program with Whitley Drugs.

I authorize Whitley Drugs to use information I provided to Camp for prescriptions

Please list all prescription medications.

Medication Strength Direction Prescription Doctor (Primary or Specialist) Special Instruction(Example: Brand or generic)

Please list all over-the-counter medications (OTC) and/or vitamins *these will require original prescriptions in order to be processed and given at camp. These will *not* be able to be given at camp without an accompanying prescription.

Medication Name Strength Dosage Form(Example: Capsule, table, etc) Direction Special Instruction(Example: Brand or generic)

Provide prescription insurance information that can be found on the camper or primary plan holder prescription benefit card.

We require a credit card to charge all copays and packaging fees. Packaging fees are $30 for any camp session lasting less than 15 days and $60 for any camp session lasting more than 15 days. *This charge is per camper, not per medication.* If you do not feel comfortable entering your credit card information, please feel free to contact Whitley Drugs at 828-692-4236 and we would be happy to take it over the phone.