Camp Moshava Wild Rose Medication Form

It is a camp requirement that all medications, vitamins, and supplements that are given daily and “as needed” be ordered through Rosens Morseview Pharmacy. This includes (but is not limited to) prescription medications, over the counter allergy medication, multivitamins, and melatonin.

The following medications CAN be brought to camp but MUST be in original packaging with prescription label attached; Growth Hormone or other injectable medications, Inhalers, Epipens, Accutane, Compounded Medications, Birth Control.

The following medications are stocked at camp and do not need to be ordered unless your child takes them on a scheduled basis; Tylenol (Acetaminophen), Advil/Motrin (Ibuprofen), Benadryl (Diphenhydramine), Robitussin, Mucinex, Imodium, Maalox, Pepto-Bismol, Tums, Phenylephrine HCL

Medication at camp is distributed before breakfast, before lunch, before dinner, and before bedtime.

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 Both Sessions

Parent Name

Parent Phone #

Parent Email

Medication Information

Please list all prescription medications, over the counter medications, vitamins, and supplements that your child will be taking at camp. If you are unsure if your child's medication needs to be ordered through the pharmacy, please refer to the instructions above or contact the camp directly. Any camper who brings medications, vitamins, or supplements to camp without prior permission from the camp medical staff will be charged $150

Add new row

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 Responsibilty

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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