New Camper or Counselor Enrollment Form

* 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!

Camp Location *

Camper / Counselors Name

First Name *

Last Name *

Gender *

Male

Female

Date of Birth *

Check-in Date of Camp *

Street Address *

City *

State *

Zip Code *

Contact Information

Name of the Contact Person

First Name *

Last Name *

Relation to the Camper / Counselor *

Primary Phone Number *

Cell Phone Number *

Campers Primary Care Providers / Physicians and Current Pharmacy

Primary Care Physician Name

Phone Number

Secondary / Specialty Care Physician Name

Phone Number

Current Pharmacy Name

City

State

Current Pharmacy Phone Number

Enrollment and Credit Card Authorization *

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

Parent / Guardian Signature

Date

Does the camper have any allergies that the pharmacist needs to be aware of? *

Yes

Please provide as much details to allergies as known. The pharmacist may call back to verify

Prescription Medications

Please list all prescription medications.

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

Over The Counter Medications and Vitamins

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)

Camper / Counselor Prescription Insurance Information

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

Primary Cardholder ID Number

RX BIN Number

RX PCN Number

RX Group Number

Person Code

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.

Card Number

Expiration Date

CVV Code