Camp Marimeta Medication Form

Does your camper take medications more than 1 time per week?
If so, this form is for you!
If not, no need to complete this form!
All medication that is taken on a regular basis (2x a week or more) must be filled through this online form. This means that prescription AND over the counter medications such as vitamins, allergy medications, etc. must be filled through this form.

Fields marked with an * are required

Contact Information

Camper’s Full Name

Camper’s Birthdate

Address

Address 2

City

State

Zip Code

Session

First Session Second Session 8 Weeks

Parent Name

Parent Phone #

Parent Email

Medication Information

Please list all your camper’s medications she will take at camp on a regular basis.
What’s a regular basis?
Anything your child takes two times a week or more.
For example: we do not need you to list medications such as Tylenol if she only takes it when she has a headache, we have that at camp!
However, if she takes Tylenol 3 times a week, it must be listed and sent through Rosens pharmacy. All prescription medications must be listed here, too.

If you do not fill medications through this form and we need to bag your camper’s medications at camp there will be a $150 charge per session!

Add another medication

Allergies?

Medical Conditions?

Doctor Information

Rosens-Morseview Pharmacy will contact your camper’s doctor to get prescriptions. If all medications are over the counter, please provide your child’s primary care physician information only.

Primary Doctor Name

Doctor Phone #

Doctor Fax #

Doctor Address, City, State, Zip Code

Specialty Doctor Name

Doctor Phone #

Doctor Fax #

Doctor Specialty

Doctor Address, City, State, Zip Code

Insurance Responsibility

I understand that all medications and pharmacy services are subject to insurance approval at the time of processing. Rosens Pharmacy will take every measure to utilize your insurance benefits. Insurance coverage decisions, including denials, limitations, and prior authorization requirements, are determined by the insurance provider. Any medications or services not covered by insurance are my financial responsibility.

Insurance Information

Insurance Company Name

Insurance Phone # (on back of card)

Identification Number

RX Group Number

RX Bin Number

RX PCN Number

Camper Relationship to Cardholder

Credit Card Authorization

Any payments due are processed through Rosens-Morseview Pharmacy. There will be a $35 packaging charge per session. A $50 late fee will apply if this form is not turned in by May 1st prior to the camping season.

Credit Card Information

Visa Mastercard Discover American Express

Name on Card

Credit Card Number

Expiration Date

MM/YY

CVV Code

I authorize Rosens Morseview Pharmacy to charge my credit card above for agreed upon purchase(s). I understand that my information will be saved for the duration of the camp season only.

If a payment method is declined, I agree to promptly provide an alternative form of payment upon notification. Outstanding balances not resolved within an agreed-upon timeframe may be subject to reasonable late fees, as permitted by law.

Authorization and Acknowledgement

By completing the line below, I confirm that I have read, understand, and agree to the terms outlined in this form. I certify that I am the parent or legal guardian of the camper named above and authorize medication administration and pharmacy services as described.

Printed Name

Today's Date

MM/DD/YY

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